Practice Relating to Rule 29. Medical Transports

Geneva Convention I
Article 36 of the 1949 Geneva Convention I provides:
Medical aircraft, that is to say, aircraft exclusively employed for the removal of wounded and sick and for the transport of medical personnel and equipment, shall not be attacked, but shall be respected by the belligerents, while flying at heights, times and on routes specifically agreed upon between the belligerents concerned.
Unless agreed otherwise, flights over enemy or enemy-occupied territory are prohibited.
Medical aircraft shall obey every summons to land. In the event of a landing thus imposed, the aircraft with its occupants may continue its flight after examination, if any.
In the event of an involuntary landing in enemy or enemy-occupied territory, the wounded and sick, as well as the crew of the aircraft shall be prisoners of war. The medical personnel shall be treated according to Article 24 and the Articles following. 
Convention (I) for the Amelioration of the Condition of the Wounded and Sick in Armed Forces in the Field, Geneva, 12 August 1949, Article 36.
Geneva Convention IV
Article 22 of the 1949 Geneva Convention IV provides:
Aircraft exclusively employed for the removal of wounded and sick civilians, the infirm and maternity cases or for the transport of medical personnel and equipment, shall not be attacked, but shall be respected while flying at heights, times and on routes specifically agreed upon between all the Parties to the conflict concerned … Unless agreed otherwise, flights over enemy or enemy occupied territory are prohibited. Such aircraft shall obey every summons to land. In the event of a landing thus imposed, the aircraft with its occupants may continue its flight after examination, if any. 
Convention (IV) relative to the Protection of Civilian Persons in Time of War, Geneva, 12 August 1949, Article 22.
Additional Protocol I
Article 25 of the 1977 Additional Protocol I provides:
In and over land areas physically controlled by friendly forces, or in and over sea areas not physically controlled by an adverse Party, the respect and protection of medical aircraft of a Party to the conflict is not dependent on any agreement with an adverse Party. For greater safety, however, a Party to the conflict operating its medical aircraft in these areas may notify the adverse Party, as provided in Article 29, in particular when such aircraft are making flights bringing them within range of surface-to-air weapons systems of the adverse Party. 
Protocol Additional to the Geneva Conventions of 12 August 1949, and relating to the Protection of Victims of International Armed Conflicts (Protocol I), Geneva, 8 June 1977, Article 25. Article 25 was adopted by consensus. CDDH, Official Records, Vol. VI, CDDH/SR.38, 24 May 1977, p. 89.
Additional Protocol I
Article 26 of the 1977 Additional Protocol I provides:
1. In and over those parts of the contact zone which are physically controlled by friendly forces and in and over those areas the physical control of which is not clearly established, protection for medical aircraft can be fully effective only by prior agreement between the competent military authorities of the Parties to the conflict, as provided for in Article 29. Although, in the absence of such an agreement, medical aircraft operate at their own risk, they shall nevertheless be respected after they have been recognized as such.
2. “Contact zone” means any area on land where the forward elements of opposing forces are in contact with each other, especially where they are exposed to direct fire from the ground. 
Protocol Additional to the Geneva Conventions of 12 August 1949, and relating to the Protection of Victims of International Armed Conflicts (Protocol I), Geneva, 8 June 1977, Article 26. Article 26 was adopted by consensus. CDDH, Official Records, Vol. VI, CDDH/SR.39, 25 May 1977, p. 94.
Additional Protocol I
Article 27 of the 1977 Additional Protocol I provides:
1. The medical aircraft of a Party to the conflict shall continue to be protected while flying over land or sea areas physically controlled by an adverse Party, provided that prior agreement to such flights has been obtained from the competent authority of that adverse Party.
2. A medical aircraft which flies over an area physically controlled by an adverse Party without, or in deviation from the terms of, an agreement provided for in paragraph 1, either through navigational error or because of an emergency affecting the safety of the flight, shall make every effort to identify itself and to inform the adverse Party of the circumstances. As soon as such medical aircraft has been recognized by the adverse Party, that Party shall make all reasonable efforts to give the order to land or to alight on water, referred to in Article 30, paragraph 1, or to take other measures to safeguard its own interests, and, in either case, to allow the aircraft time for compliance, before resorting to an attack against the aircraft. 
Protocol Additional to the Geneva Conventions of 12 August 1949, and relating to the Protection of Victims of International Armed Conflicts (Protocol I), Geneva, 8 June 1977, Article 27. Article 27 was adopted by consensus. CDDH, Official Records, Vol. VI, CDDH/SR.39, 25 May 1977, p. 95.
Additional Protocol I
Article 28 of the 1977 Additional Protocol I provides:
1. The Parties to the conflict are prohibited from using their medical aircraft to attempt to acquire any military advantage over an adverse Party. The presence of medical aircraft shall not be used in an attempt to render military objectives immune from attack.
2. Medical aircraft shall not be used to collect or transmit intelligence data and shall not carry any equipment intended for such purposes. They are prohibited from carrying any persons or cargo not included within the definition in Article 8, sub-paragraph f). The carrying on board of the personal effects of the occupants or of equipment intended solely to facilitate navigation, communication or identification shall not be considered as prohibited.
3. Medical aircraft shall not carry any armament except small arms and ammunition taken from the wounded, sick and shipwrecked on board and not yet handed to the proper service, and such light individual weapons as may be necessary to enable the medical personnel on board to defend themselves and the wounded, sick and shipwrecked in their charge. 
Protocol Additional to the Geneva Conventions of 12 August 1949, and relating to the Protection of Victims of International Armed Conflicts (Protocol I), Geneva, 8 June 1977, Article 28. Article 28 was adopted by consensus. CDDH, Official Records, Vol. VI, CDDH/SR.39, 25 May 1977, p. 97.
San Remo Manual
Paragraph 53(a) of the 1994 San Remo Manual provides that medical aircraft are exempt from attack. Paragraph 54 lists the following conditions of exemption:
Medical aircraft are exempt from attack only if they:
(a) have been recognised as such;
(b) are acting in compliance with an agreement …
(c) fly in areas under the control of own or friendly forces; or
(d) fly outside the area of armed conflict.
In other instances, medical aircraft operate at their own risk. 
Louise Doswald-Beck (ed.), San Remo Manual on International Law Applicable to Armed Conflicts at Sea, 12 June 1994, Prepared by international lawyers and naval experts convened by the International Institute of Humanitarian Law, Cambridge University Press, Cambridge, 1995, §§ 53(a) and 54.
San Remo Manual
Paragraph 178 of the 1994 San Remo Manual states:
Medical aircraft shall not be used to commit acts harmful to the enemy. They shall not carry any equipment intended for the collection or transmission of intelligence data. They shall not be armed, except for small arms for self-defence, and shall only carry medical personnel and equipment. 
Louise Doswald-Beck (ed.), San Remo Manual on International Law Applicable to Armed Conflicts at Sea, 12 June 1994, Prepared by international lawyers and naval experts convened by the International Institute of Humanitarian Law, Cambridge University Press, Cambridge, 1995, § 178.
Argentina
Argentina’s Law of War Manual (1969) restates Article 36 of the 1949 Geneva Convention I and Article 22 of the 1949 Geneva Convention IV. 
Argentina, Leyes de Guerra, RC-46-1, Público, II Edición 1969, Ejército Argentino, Edición original aprobado por el Comandante en Jefe del Ejército, 9 May 1967, §§ 3.017 and 4.006.
Australia
Australia’s Defence Force Manual (1994) states:
972. … Medical aircraft must be respected and protected at all times and must not be attacked. Their immunity ceases once they are used for purposes hostile to the adverse party and outside their humanitarian purpose.
977. Medical aircraft may fly over land physically controlled by their own or friendly forces, and over sea areas not under enemy control. However, it is advisable that the enemy be informed if such flights are likely to bring the aircraft within range of enemy surface-to-air weapon systems.
978. In accordance with LOAC, flight of such aircraft over enemy or enemy-occupied territory is forbidden without prior agreement. In the absence of such agreement, medical aircraft operating in parts of the zone controlled by friendly forces, and over areas the control of which is doubtful, do so at their own risk, but once they are recognised as medical aircraft they must be respected.
979. Provided prior agreement has been obtained from the enemy, medical aircraft belonging to a combatant remain protected while flying over land or sea areas under the physical control of the enemy. If it deviates for any reason from the terms of such an agreement, the aircraft shall take immediate steps to identify itself. Upon being recognised as a medical aircraft, the adverse party may order it to land, or take such other steps to safeguard its own interests, and must allow time for compliance before attacking the aircraft.
980. Known medical aircraft are entitled to protection while performing medical functions … Medical aircraft must not be used in order to gain any military advantage and while carrying out flights in accordance with the two preceding paragraphs, shall not, without prior agreement, be used to search for the wounded, sick and shipwrecked. 
Australia, Manual on Law of Armed Conflict, Australian Defence Force Publication, Operations Series, ADFP 37 – Interim Edition, 1994, §§ 972 and 977–980.
Australia
Australia’s LOAC Manual (2006) states:
Medical aircraft, that is, aircraft exclusively employed for the removal of wounded and sick for the transport of medical personnel and equipment, shall not be attacked, but shall be respected by the belligerents, while flying at heights, at times and on routes specifically agreed upon between the belligerents concerned. These aircraft should bear clearly marked, distinctive emblems, together with their national colours on their upper and lower surfaces. 
Australia, The Manual of the Law of Armed Conflict, Australian Defence Doctrine Publication 06.4, Australian Defence Headquarters, 11 May 2006, § 5.44.
In its chapter on “Protected Persons and Objects”, the manual states:
9.78 Medical … aircraft must be respected and protected at all times and must not be attacked. Their immunity ceases once they are used for purposes hostile to the adverse party and outside their humanitarian purpose.
9.83 Medical aircraft may fly over land physically controlled by their own or friendly forces, and over sea areas not under enemy control. However, it is advisable that the enemy be informed if such flights are likely to bring the aircraft within range of enemy surface-to-air weapon systems.
9.84 In accordance with the LOAC, flight of such aircraft over enemy or enemy-occupied territory is forbidden without prior agreement. In the absence of such agreement, medical aircraft operating in parts of the zone controlled by friendly forces, and over areas the control of which is doubtful, do so at their own risk, but once they are recognised as medical aircraft they must be respected.
9.85 Provided prior agreement has been obtained from the enemy, medical aircraft belonging to a combatant remain protected while flying over land or sea areas under the physical control of the enemy. If it deviates for any reason from the terms of such an agreement, the aircraft shall take immediate steps to identify itself. Upon being recognised as a medical aircraft, the adverse party may order it to land, or take such other steps to safeguard its own interests, and must allow time for compliance before attacking the aircraft.
9.86 Known medical aircraft are entitled to protection when performing medical functions … Medical aircraft must not be used in order to gain any military advantage and while carrying out flights in accordance with the two preceding paragraphs, shall not, without prior agreement, be used to search for the wounded, sick and shipwrecked. 
Australia, The Manual of the Law of Armed Conflict, Australian Defence Doctrine Publication 06.4, Australian Defence Headquarters, 11 May 2006, §§ 9.78 and 9.83–9.86; see also §§ 8.49 and 8.60–8.63.
The manual further states: “Among other war crimes generally recognised as forming part of the customary LOAC are … attacking a properly marked … medical aircraft”. 
Australia, The Manual of the Law of Armed Conflict, Australian Defence Doctrine Publication 06.4, Australian Defence Headquarters, 11 May 2006, § 13.30.
The LOAC Manual (2006) replaces both the Defence Force Manual (1994) and the Commanders’ Guide (1994).
Belgium
Belgium’s Law of War Manual (1983) states:
Medical aircraft are immune from attack during the flights agreed upon beforehand between belligerents. They may not fly over enemy controlled or occupied territory without authorization. They must obey each order to land … No authorization is necessary to fly over territory controlled by one’s own forces. Medical aircraft are still protected above contact zones, but the risk of sustaining damage are bigger in the absence of an agreement. 
Belgium, Droit Pénal et Disciplinaire Militaire et Droit de la Guerre, Deuxième Partie, Droit de la Guerre, Ecole Royale Militaire, par J. Maes, Chargé de cours, Avocat-général près la Cour Militaire, D/1983/1187/029, 1983, p. 49.
Canada
Canada’s LOAC Manual (1999) states: “Medical aircraft, correctly identified and exclusively used as such, are immune from attack.” 
Canada, The Law of Armed Conflict at the Operational and Tactical Level, Office of the Judge Advocate General, 1999, p. 7-5, § 43.
The manual further states:
41. Medical aircraft are free to fly over land physically controlled by their own or friendly forces, and over sea areas not under enemy control. It is advisable, however, that the adverse party be informed if such flights are likely to bring the aircraft within range of surface-to-air weapon systems of the adverse party.
42. Flight of medical aircraft over enemy or enemy-occupied territory is forbidden without prior agreement. In the absence of such agreement, medical aircraft operating in parts of the contact zone controlled by friendly forces, and over areas the control of which is doubtful, do so at their own risk. “Contact zone” means any area on land where the forward elements of opposing forces are in contact with each other, especially where they are exposed to direct fire from the ground.
43. Provided prior agreement has been obtained from the adverse party, medical aircraft belonging to a combatant remain protected while flying over land or sea areas under the physical control of the adverse party. If the aircraft lags or deviates for any reason from the terms of the agreement, the aircraft shall take immediate steps to identify itself. Upon being recognized as a medical aircraft, the adverse party may order it to land, or take such other steps to safeguard its own interests, but must allow time for compliance before attacking the aircraft.
44. Medical aircraft must not be used in order to gain any military advantage. While carrying out flights, medical aircraft shall not, without prior agreement, be used to search for the wounded, sick and shipwrecked. 
Canada, The Law of Armed Conflict at the Operational and Tactical Level, Office of the Judge Advocate General, 1999, p. 9-4, §§ 41–44 and p. 11-3, § 22.
The manual qualifies “attacking a properly marked … medical aircraft” as a war crime. 
Canada, The Law of Armed Conflict at the Operational and Tactical Level, Office of the Judge Advocate General, 1999, p. 16-4, § 21(e).
Canada
Canada’s LOAC Manual (2001) states in its chapter on air warfare:
1. Medical aircraft, correctly identified and exclusively used as such, are immune from attack.
2. The parties to a conflict may, by agreement, confer immunity from attack upon specific aircraft. Such aircraft remain protected so long as they take no part in hostilities and rigorously respect the conditions laid down in the agreement. 
Canada, The Law of Armed Conflict at the Operational and Tactical Levels, Office of the Judge Advocate General, 13 August 2001, § 715.
In its chapter on the treatment of the wounded, sick and shipwrecked, the manual states:
918. Protection of medical establishments, transport, aircraft and hospital ships
1. Medical establishments on land, hospital ships, medical aircraft, and medical transports must be respected and protected at all times and must not be attacked. If they are used for purposes hostile to the adverse party and outside their humanitarian purpose, protection may cease. Protection will only cease, however, following a clear warning which has remained unheeded.
921. Medical aircraft
1. Medical aircraft are free to fly over land physically controlled by their own or friendly forces, and over sea areas not under enemy control. It is advisable; however, that the adverse party be informed if such flights are likely to bring the aircraft within range of surface-to-air weapon systems of the adverse party.
2. Flight of medical aircraft over enemy or enemy-occupied territory is forbidden without prior agreement. In the absence of agreement, medical aircraft operating in parts of the contact zone controlled by friendly forces, and over areas the control of which is doubtful, do so at their own risk. “Contact zone” means any area on land where the forward elements of opposing forces are in contact with each other, especially where they are exposed to direct fire from the ground.
3. Provided prior agreement has been obtained from the adverse party, medical aircraft belonging to a combatant remain protected while flying over land or sea areas under the physical control of the adverse party. If the aircraft lags or deviates for any reason from the terms of the agreement, the aircraft shall take immediate steps to identify itself. Upon being recognized as a medical aircraft the adverse party may order it to land, or take such other steps to safeguard its own interests, but must allow time for compliance before attacking the aircraft.
4. Medical aircraft must not be used in order to gain any military advantage. While carrying out flights medical aircraft shall not, without prior agreement, be used to search for the wounded, sick and shipwrecked.
5. If a medical aircraft is ordered by an adverse party to land, it must obey such order and permit inspection. Wounded and sick on board may only be removed if this is essential to enable the inspection to proceed, and only if such removal does not adversely affect their welfare. If the inspection of a landed aircraft, discloses that the aircraft is in fact a medical aircraft, and is not in breach of any special agreement or in violation of the law relating to medical aircraft, the aircraft and its occupants belonging to the aircraft’s state or a neutral country must be allowed to leave.
6. If the aircraft does not satisfy these requirements it may be seized. If, however, the aircraft has been assigned as a permanent medical aircraft, it may be used by the captor only for this purpose. If the aircraft makes an involuntary landing in enemy or enemy-occupied territory, the sick, wounded and shipwrecked as well as the crew become PWs [prisoners of war] but the medical personnel must be treated in the same way as other medical personnel falling into enemy hands.
7. Medical aircraft shall not fly over neutral territory without prior approval. If a medical aircraft should fly over neutral territory without agreement for any reason, it must make every effort to give notice and identify itself. The medical aircraft must obey any order to land and it cannot be attacked until a reasonable time for compliance has elapsed. When the aircraft lands, it is liable to inspection and if found to be a medical aircraft may leave with its occupants, other than those who must be detained in accordance with International Law. If the wounded, sick or shipwrecked are removed for other than temporary reasons, they must be detained in a manner that precludes their taking any further part in the hostilities. Any restrictions applied by a neutral must be applied to all Parties to the conflict equally. 
Canada, The Law of Armed Conflict at the Operational and Tactical Levels, Office of the Judge Advocate General, 13 August 2001, §§ 918 and 921.
In its chapter entitled “Treatment of civilians in the hands of a party to the conflict or an occupying power”, the manual states:
Aircraft used exclusively for the removal of wounded and sick civilians, or for the transport of medical personnel and equipment must not be attacked when flying at heights, times and on routes specifically agreed upon between all the belligerents concerned. Such aircraft may be marked with the Red Cross or Red Crescent distinctive emblem. In the absence of agreement to the contrary, flights over enemy or enemy-occupied territory are prohibited. Such aircraft must obey every summons to land, but, after landing and examination, may continue their flight. 
Canada, The Law of Armed Conflict at the Operational and Tactical Levels, Office of the Judge Advocate General, 13 August 2001, § 1112.2.
In its chapter on “War crimes, individual criminal liability and command responsibility”, the manual qualifies “attacking a properly marked … medical aircraft” as a war crime. 
Canada, The Law of Armed Conflict at the Operational and Tactical Levels, Office of the Judge Advocate General, 13 August 2001, § 1609.3.e.
Croatia
Croatia’s Commanders’ Manual (1992) provides: “Medical transports may not be used to collect or transmit intelligence data.” 
Croatia, Basic Rules of the Law of Armed Conflicts – Commanders’ Manual, Republic of Croatia, Ministry of Defence, 1992, § 34.
Croatia
Croatia’s Soldiers’ Manual (1992) instructs soldiers to respect medical aircraft displaying the distinctive emblem. 
Croatia, Rules of Conduct for Soldiers, Republic of Croatia, Ministry of Defence, 1992, pp. 2 and 3.
Dominican Republic
The Dominican Republic’s Military Manual (1980) directs soldiers not to attack medical aircraft. 
Dominican Republic, La Conducta en Combate según las Leyes de la Guerra, Escuela Superior de las FF. AA. “General de Brigada Pablo Duarte”, Secretaría de Estado de las Fuerzas Armadas, May 1980, p. 4.
Ecuador
Ecuador’s Naval Manual (1989) qualifies “deliberate attack upon … medical aircraft” as a war crime. 
Ecuador, Aspectos Importantes del Derecho Internacional Marítimo que Deben Tener Presente los Comandantes de los Buques, Academia de Guerra Naval, 1989, § 6.2.5.
Ethiopia
According to Ethiopia’s Standing Rules of Engagement (2007), “ambulance airplanes” do not constitute military objectives. 
Ethiopia, Standing Rules of Engagement, National Defense Force, Addis Ababa, 2007, § 8.4.5.
France
France’s LOAC Summary Note (1992) states: “Medical transports must not be used to collect military information.” 
France, Fiche de Synthèse sur les Règles Applicables dans les Conflits Armés, Note No. 432/DEF/EMA/OL.2/NP, Général de Corps d’Armée Voinot (pour l’Amiral Lanxade, Chef d’Etat-major des Armées), 1992, § 2.3.
Germany
Germany’s Military Manual (1992) states:
The parties to the conflict are prohibited from using their medical aircraft to attempt to acquire any military advantage over an adverse party. The presence of medical aircraft shall not be used in an attempt to render military objectives immune from attack. 
Germany, Humanitarian Law in Armed Conflicts – Manual, DSK VV207320067, edited by The Federal Ministry of Defence of the Federal Republic of Germany, VR II 3, August 1992, English translation of ZDv 15/2, Humanitäres Völkerrecht in bewaffneten KonfliktenHandbuch, August 1992, § 620.
Greece
The Hellenic Navy’s International Law Manual (1995) provides:
[T]he protection of any type of hospital vessels and boats is conventionally consolidated. The same protection is extended to medical aircrafts (art. 36 of the Ist Geneva Convention and art. 24, 25, 27–30 of Ist Add. Protocol) and according to practice followed during the Falklands war also to helicopters used for carrying the wounded, shipwrecked and the dead. 
Greece, International Law Manual, Hellenic Navy General Staff, Directorate A2, Division IV, 1995, Chapter 7, Part I, § 7.
Guinea
Guinea’s Soldier’s Manual (2010), under the heading “Distinctive signs”, shows an image of a helicopter with a red crescent on a white ground and states: “Let these … aircraft move around and do not enter them.” 
Guinea, Soldier’s Manual, Ministry of National Defence, 2010, p. 14.
Hungary
Hungary’s Military Manual (1992) states that “medical aircraft flying over the high seas, on specified routes, according to an agreement or identified as such” must be protected. 
Hungary, A Hadijog, Jegyzet a Katonai, Föiskolák Hallgatói Részére, Magyar Honvédség Szolnoki Repülötiszti Föiskola, 1992, p. 71.
Indonesia
Indonesia’s Air Force Manual (1990) states that medical aircraft must not be attacked, provided they fly on routes, heights and at times agreed between belligerents. The manual further states that medical aircraft lose their immunity if they are used for purposes other than the transportation of the wounded, medical personnel or medical equipment. 
Indonesia, The Basics of International Humanitarian Law in Air Warfare, Indonesian Air Force, 1990, § 36.
The manual also states that no immunity is provided to medical aircraft which enter a war zone or enemy controlled territory without prior authorization or without agreement between the parties to the conflict or when they ignore instructions given by the parties to the conflict. 
Indonesia, The Basics of International Humanitarian Law in Air Warfare, Indonesian Air Force, 1990, § 46.
Italy
Italy’s LOAC Elementary Rules Manual (1991) provides: “Medical transports may not be used to collect or transmit intelligence data.”  
Italy, Regole elementari di diritto di guerra, SMD-G-012, Stato Maggiore della Difesa, I Reparto, Ufficio Addestramento e Regolamenti, Rome, 1991, § 34.
Italy
Italy’s IHL Manual (1991) provides: “Medical aircraft attached to the military [medical] service must be respected and protected.” 
Italy, Manuale di diritto umanitario, Introduzione e Volume I, Usi e convenzioni di Guerra, SMD-G-014, Stato Maggiore della Difesa, I Reparto, Ufficio Addestramento e Regolamenti, Rome, 1991, Vol. I, § 14.
Lebanon
Lebanon’s Teaching Manual (1997) provides for respect for aircraft displaying the distinctive emblem. 
Lebanon, Manuel de l’Instruction Nationale dans l’Armée Libanaise, 1997, p. 77.
Mexico
Mexico’s Army and Air Force Manual (2009), in a section on the 1949 Geneva Convention II, states:
Medical aircraft exclusively employed for the removal of the wounded, sick and shipwrecked and for the transport of medical supplies must be respected by the parties to the conflict, while flying at heights, at times and on routes specifically agreed upon between the parties to the conflict. Unless agreed otherwise, flights over enemy or enemy-occupied territory are prohibited. 
Mexico, Manual de Derecho Internacional Humanitario para el Ejército y la Fuerza Área Mexicanos, Ministry of National Defence, June 2009, § 129.
Netherlands
The Military Manual (1993) of the Netherlands restates the rules governing medical aircraft found in Articles 25–28 of the 1977 Additional Protocol I. 
Netherlands, Toepassing Humanitair Oorlogsrecht, Voorschift No. 27-412/1, Koninklijke Landmacht, Ministerie van Defensie, 1993, pp. VI-6 and VI-7.
Netherlands
The Military Manual (2005) of the Netherlands states:
0627. Medical aircraft
Special rules exist for the protection of medical aircraft. First, they distinguish between the places where such aircraft are flying:
- in zones under the control of friendly troops;
- in contact zones;
- in zones under the control of the adversary.
0628. Zones under friendly control
In a situation where medical aircraft are flying in zones under the control of friendly troops, no rules are prescribed, except that, for safety’s sake, the adversary may be informed when and where medical aircraft are carrying out flights.
0629. Contact zones
A contact zone means any area on land where the parties’ forces are fighting each other. If the parties in a conflict have reached no agreement on flights in the contact zone, medical aircraft fly at their own risk. An adversary which recognizes a medical aircraft must, of course, respect it.
0630. Zones under the adversary’s control
Subject to obtaining the adversary’s permission, medical aircraft enjoy total protection while flying over the area under the adversary’s control. If permission is not obtained, or if the aeroplane or helicopter strays from the prescribed route, or breaches other set conditions, it must identify itself as quickly as possible to the adversary which should make every reasonable effort to order a medical aircraft, identified as such, to land, or should take other measures before attacking the aircraft. If one of the parties to a conflict forces a medical aircraft to land and it emerges, on inspection, that the consignment does not meet certain specific requirements for medical flights, the plane may be seized. In the case of a dedicated medical plane, it may be used only as such thereafter.
0631. A number of further rules apply to the use of medical aircraft in general. Medical aircraft may not be used in an attempt to render military objectives immune from attack. It is also prohibited to use such aircraft to gather military intelligence or carry equipment for that purpose, or otherwise to procure any advantage against the adversary. Medical aircraft may carry only the wounded, the sick, medical personnel and religious personnel. Furthermore, only portable weapons and ammunition of the persons present on board the aircraft may be carried with them. 
Netherlands, Humanitair Oorlogsrecht: Handleiding, Voorschift No. 27-412, Koninklijke Landmacht, Militair Juridische Dienst, 2005, §§ 0627–0631.
In its chapter on neutrality, the manual states:
Except with consent and the possible attachment of conditions or restrictions, medical aircraft may not over-fly or land on the territory of a neutral State or other State not a party to the conflict. If consent is obtained, medical aircraft should be respected and protected. Nevertheless, they must obey any order to land.
If consent is not obtained, a medical aircraft should do everything to announce the flight and to identify itself. 
Netherlands, Humanitair Oorlogsrecht: Handleiding, Voorschift No. 27-412, Koninklijke Landmacht, Militair Juridische Dienst, 2005, § 0940.
New Zealand
New Zealand’s Military Manual (1992) states: “Medical aircraft, correctly identified and exclusively used as such, are for the main part immune from attack.” 
New Zealand, Interim Law of Armed Conflict Manual, DM 112, New Zealand Defence Force, Headquarters, Directorate of Legal Services, Wellington, November 1992, § 629.1.
The manual further states: “Medical aircraft must be respected and protected at all times and must not be attacked. Their immunity ceases once they are used for purposes hostile to the adverse Party and outside their humanitarian purposes.” 
New Zealand, Interim Law of Armed Conflict Manual, DM 112, New Zealand Defence Force, Headquarters, Directorate of Legal Services, Wellington, November 1992, § 1007(1).
The manual restates the rules governing medical aircraft found in Articles 25–28 of the 1977 Additional Protocol I. 
New Zealand, Interim Law of Armed Conflict Manual, DM 112, New Zealand Defence Force, Headquarters, Directorate of Legal Services, Wellington, November 1992, § 1009(1)-(5).
In addition, the manual specifies that:
Aircraft used exclusively for the removal of wounded and sick civilians, the infirm and maternity cases, or for the transport of medical personnel and equipment must not be attacked when flying at heights, times and on routes specifically agreed upon between all the belligerents concerned … In the absence of agreement to the contrary, flights over enemy or enemy-occupied territory are prohibited. Such aircraft must obey every order to land, but, after landing and examination, may continue their flight. 
New Zealand, Interim Law of Armed Conflict Manual, DM 112, New Zealand Defence Force, Headquarters, Directorate of Legal Services, Wellington, November 1992, § 1110(2).
According to the manual, “attacking a properly marked … medical aircraft” constitutes a war crime recognized by the customary law of armed conflict. 
New Zealand, Interim Law of Armed Conflict Manual, DM 112, New Zealand Defence Force, Headquarters, Directorate of Legal Services, Wellington, November 1992, § 1704(5).
Nicaragua
Nicaragua’s Military Manual (1996) states, with respect to international armed conflicts, that assistance to the wounded, sick and shipwrecked includes a requirement of “respect for medical aircraft assigned to the evacuation of the wounded and the sick and the transportation of medical personnel and equipment” and “respect for aircraft used to transfer civilian wounded and sick, disabled and elderly or to transport medical personnel or material”. 
Nicaragua, Manual de Comportamiento y Proceder de las Unidades Militares y de los Miembros del Ejército de Nicaragua en Tiempo de Paz, Conflictos Armados, Situaciones Irregulares o Desastres Naturales, Ejército de Nicaragua, Estado Mayor General, Asesoría Jurídica del Nicaragua, 1996, Article 14(8) and (39).
Peru
Peru’s IHL Manual (2004) states: “The following classes of enemy aircraft are exempt from attack: … medical aircraft”. 
Peru, Manual de Derecho Internacional Humanitario para las Fuerzas Armadas, Resolución Ministerial Nº 1394-2004-DE/CCFFAA/CDIH-FFAA, Lima, 1 December 2004, § 129.d.(1).(a); see also § 87.a and b.
The manual further states:
Medical aircraft are exempt from attack only if they:
(1) have been recognized as such;
(2) are acting in compliance with an agreement; parties to the conflict are encouraged to notify medical flights and conclude agreements at all times, especially in areas where control by any party to the conflict is not clearly established; when such an agreement is concluded, it shall specify the altitudes, times and routes for safe operation and should include means of identification and communication;
(3) fly in areas under the control of own or friendly forces;
(4) fly outside the area of armed conflict.
In other instances, medical aircraft operate at their own risk.  
Peru, Manual de Derecho Internacional Humanitario para las Fuerzas Armadas, Resolución Ministerial Nº 1394-2004-DE/CCFFAA/CDIH-FFAA, Lima, 1 December 2004, § 129.e.
The manual also states:
Agreements or notifications are required for medical aircraft flying over areas controlled by enemy forces or contact zones.
Medical aircraft may not be used under any circumstances to obtain military information or to search for wounded and shipwrecked persons unless a prior agreement has been made.
Medical aircraft can be inspected. They can be confiscated if the inspection discloses that the aircraft:
(1) is not a medical aircraft;
(2) is being used to gain a military advantage;
(3) has flown without or in breach of a prior agreement.
Aircraft seized in this manner become war booty. 
Peru, Manual de Derecho Internacional Humanitario para las Fuerzas Armadas, Resolución Ministerial Nº 1394-2004-DE/CCFFAA/CDIH-FFAA, Lima, 1 December 2004, § 110.c.
Peru
Peru’s IHL and Human Rights Manual (2010) states: “The following classes of enemy aircraft are exempt from attack: … medical aircraft”. 
Peru, Manual de Derecho Internacional Humanitario y Derechos Humanos para las Fuerzas Armadas, Resolución Ministerial No. 049-2010/DE/VPD, Lima, 21 May 2010, § 120(d)(1)(a), p. 311.
The manual also states:
g. Conditions for immunity [from attack] of medical aircraft
Medical aircraft are exempt from attack only if they:
(1) have been recognized as such;
(2) are acting in compliance with an agreement; parties to the conflict are encouraged to notify medical flights and conclude agreements at all times, especially in areas where control by any party to the conflict is not clearly established. When such an agreement is concluded, it shall specify the altitudes, times and routes for safe operation and should include means of identification and communication;
(3) fly in areas under the control of own or friendly forces;
(4) fly outside the area of armed conflict.
h. In other instances, medical aircraft operate at their own risk. 
Peru, Manual de Derecho Internacional Humanitario y Derechos Humanos para las Fuerzas Armadas, Resolución Ministerial No. 049-2010/DE/VPD, Lima, 21 May 2010, § 120(g)–(h), p. 312; see also § 149(d) and (f), pp. 335–336.
The manual further states:
149. Medical Aircraft
a. Medical aircraft must be protected and respected in accordance with the provisions in force.
e. Medical aircraft may not be used to commit acts harmful to the enemy. They may not carry equipment designed to obtain or transmit information. They may not be equipped with arms, with the exception of light weapons for self-defence, and they must only transport medical personnel and medical equipment. 
Peru, Manual de Derecho Internacional Humanitario y Derechos Humanos para las Fuerzas Armadas, Resolución Ministerial No. 049-2010/DE/VPD, Lima, 21 May 2010, § 149(a) and (e), pp. 335–336.
Russian Federation
The Russian Federation’s Military Manual (1990) states that “attack, bombardment or destruction of … medical aircraft displaying the distinctive emblems” is a prohibited method of warfare. 
Russian Federation, Instructions on the Application of the Rules of International Humanitarian Law by the Armed Forces of the USSR, Appendix to Order of the USSR Defence Minister No. 75, 1990, § 5(g).
Russian Federation
The Russian Federation’s Regulations on the Application of IHL (2001) states:
92. The following classes of enemy aircraft are exempt from attack:
- medical aircraft
They shall not be attacked only if:
a) for medical aircraft recognised as such:
- they are acting in compliance with an agreement between the parties to the conflict concerning medical flights. When such an agreement is concluded, it shall specify the altitudes, times and routes for safe operation and it shall include means of identification and communications;
- fly in areas under the control of own or friendly forces; or
- fly outside the area of armed conflict.
In case of doubt whether an aircraft exempt from attack is being used to make an effective contribution to military action, it shall be presumed not to be so used.
93. The aircraft falling under Paragraph 91 [sic] may be attacked by reason of a breach of a condition of exemption if:
- diversion for landing, visit and search, and possible capture, is not feasible;
- no other method is available for exercising military control;
- the circumstances of non-compliance are sufficiently grave that the aircraft has become, or may be reasonably assumed to be, a military objective;
- the collateral casualties or damage will not be disproportionate to the military advantage gained or anticipated.
Medical aircraft shall obey every summons to alight on land or water for inspection and search. Upon alighting on land or water the medical aircraft shall be inspected without delay and within the shortest possible time preventing any deterioration of condition of the wounded and sick. 
Russian Federation, Regulations on the Application of International Humanitarian Law by the Armed Forces of the Russian Federation, Ministry of Defence, Moscow, 8 August 2001, §§ 92–93.
The Regulations further states:
Medical aircraft … shall not be attacked if they:
- are innocently employed in their normal role;
- do not commit acts harmful to the enemy;
- immediately submit to identification and inspection when required;
- do not intentionally hamper the movement of combatants and obey orders to divert when required;
- do not violate a previously concluded agreement. 
Russian Federation, Regulations on the Application of International Humanitarian Law by the Armed Forces of the Russian Federation, Ministry of Defence, Moscow, 8 August 2001, § 92.
Sierra Leone
Sierra Leone’s Instructor Manual (2007) states:
Any means of transportation, whether military or civilian, permanent or temporary, assigned exclusively for the transportation of medical personnel, wounded and sick and other facilities are referred to as medical transport. These may include aircraft, vehicles, ships etc.
Before any transport for medical purpose, it must be marked with the protective emblem which is the Red Cross on a white background.
Medical transport is not to be attacked but may lose its [protected] status if, for example it carries arms or military equipment or the vehicle is used to gather intelligence about the location or deployment of the enemy.
It is a crime to attack a clearly marked medical transport or to use them for a non-medical purpose.
Medical transport, if captured, should be used to provide medical services to the wounded and sick. 
Sierra Leone, The Law of Armed Conflict. Instructor Manual for the Republic of Sierra Leone Armed Forces (RSLAF), Armed Forces Education Centre, September 2007, pp. 60–61.
South Africa
South Africa’s LOAC Manual (1996) provides: “Medical transport by air must also be respected, even in the absence of any overflying rights, after they have been recognised as medical aircraft.” 
South Africa, Presentation on the South African Approach to International Humanitarian Law, Appendix A, Chapter 4: International Humanitarian Law (The Law of Armed Conflict), National Defence Force, 1996, § 54.
South Africa
South Africa’s Revised Civic Education Manual (2004) states: “Medical transport by air must also be respected, even in the absence of any overflying rights, after they have been recognised as medical aircraft.” 
South Africa, Revised Civic Education Manual, South African National Defence Force, 2004, Chapter 4, § 69.
South Africa
South Africa’s LOAC Teaching Manual (2008) states:
Protected Medical Aircraft
- Extensive efforts to expand existing specific protection under treaty law for medical aircraft are currently underway.
- Generally, a medical aircraft (identified as such) should not be attacked unless under the circumstances at the time it represents an immediate military threat and other methods of control are not available.
- For example, this might occur when it approaches enemy territory or a combat zone without permission and disregards instructions, or initiates an attack.
- Attacks might also occur when the aircraft is not identified as a medical aircraft because of lack of agreement as to the height, time and route. 
South Africa, Advanced Law of Armed Conflict Teaching Manual, School of Military Justice, 1 April 2008, as amended to 25 October 2013, Learning Unit 4, p. 219.
Spain
Spain’s LOAC Manual (1996) restates the rules governing medical aircraft found in Articles 25–27 of the 1977 Additional Protocol I.  
Spain, Orientaciones. El Derecho de los Conflictos Armados, Publicación OR7-004, 2 Tomos, aprobado por el Estado Mayor del Ejército, Division de Operaciones, 18 March 1996, Vol. I, § 9.2.c.(3).
Spain
Spain’s LOAC Manual (2007) restates the rules governing medical aircraft found in Articles 25–27 of the 1977 Additional Protocol I. 
Spain, Orientaciones. El Derecho de los Conflictos Armados, Tomo 1, Publicación OR7–004, (Edición Segunda), Mando de Adiestramiento y Doctrina, Dirección de Doctrina, Orgánica y Materiales, 2 November 2007, § 9.2.c.(3).
The manual also states:
Before attacking medical aircraft flying over the contact zone without prior agreement or in deviation from the terms of agreements as regards flight corridors, identification, etc., the party must make “all reasonable efforts” to give the order to land and allow the aircraft time to comply with the order. 
Spain, Orientaciones. El Derecho de los Conflictos Armados, Tomo 1, Publicación OR7–004, (Edición Segunda), Mando de Adiestramiento y Doctrina, Dirección de Doctrina, Orgánica y Materiales, 2 November 2007, § 2.4.c.(7).
Sweden
Sweden’s IHL Manual (1991) states that Articles 25–27 of the 1977 Additional Protocol I on the protection of medical aircraft have the status of customary law. 
Sweden, International Humanitarian Law in Armed Conflict, with reference to the Swedish Total Defence System, Swedish Ministry of Defence, January 1991, Section 2.2.3, p. 18.
Switzerland
Switzerland’s Basic Military Manual (1987) provides:
Art. 91. Medical aircraft (airplanes, helicopters, etc.) exclusively used for the transport of the wounded and sick shall be respected and protected … The time, height and route of the flight, as well as the means of identification, must be agreed upon beforehand between the belligerents.
Art. 92. Unless there is an agreement to the contrary, flights over enemy territory are prohibited. Medical aircraft must obey each order to land. After inspection, they may continue their flight with their passengers. 
Switzerland, Lois et coutumes de la guerre (Extrait et commentaire), Règlement 51.7/II f, Armée Suisse, 1987, Articles 91–92.
Ukraine
Ukraine’s IHL Manual (2004) states: “‘Means of medical transportation’ means any transport used for medical (sanitary) transportation by land, sea or air … [M]eans of medical transportation may be escorted by guard or convoy.” 
Ukraine, Manual on the Application of IHL Rules, Ministry of Defence, 11 September 2004, § 1.2.35.
The manual further states: “Objects protected by international humanitarian law [include] means of medical transportation … Attacks against such objects shall be prohibited.” 
Ukraine, Manual on the Application of IHL Rules, Ministry of Defence, 11 September 2004, § 1.2.51.
United Kingdom of Great Britain and Northern Ireland
The UK Military Manual (1958) restates the rules on medical aircraft found in Article 36 of the 1949 Geneva Convention I and Article 22 of the 1949 Geneva Convention IV. 
United Kingdom, The Law of War on Land being Part III of the Manual of Military Law, The War Office, HMSO, 1958, §§ 34 and 358–359.
United Kingdom of Great Britain and Northern Ireland
The UK LOAC Pamphlet (1981) provides:
Helicopters are increasingly used for the evacuation of the wounded. Medical aircraft are protected in the same way as other medical transports, but, having regard to the range of anti-aircraft missiles, the problems of identification are greater. Overflight of enemy-held territory without prior agreement will mean loss of protection. Medical aircraft must obey summonses for inspection. Protocol I contains detailed new rules on medical aircraft and provides for light and radio recognition signals. 
United Kingdom, The Law of Armed Conflict, D/DAT/13/35/66, Army Code 71130 (Revised 1981), Ministry of Defence, prepared under the Direction of The Chief of the General Staff, 1981, Section 6, p. 24, § 12.
United Kingdom of Great Britain and Northern Ireland
The UK LOAC Manual (2004) states:
7.12. Medical transport means any means of transportation, whether military or civilian, permanent or temporary, assigned exclusively to the conveyance by land, water or air of the wounded, sick, shipwrecked, medical or religious personnel, medical equipment or medical supplies protected by the Geneva Conventions and Additional Protocol I and under the control of a competent authority of a party to the conflict. In Additional Protocol I, reference to “medical vehicles” expressly means “any medical transports by land”. Similarly, “medical ships and craft” means “any medical transports by water” and “medical aircraft” means “any medical transports by air”.
7.12.1. The assignment to medical purposes must be exclusive, although it may be permanent or temporary. The word “exclusive” is intended to restrict the definition of medical transport and its use so that the essential protection will not be eroded by abuses. “Permanent” means for an indeterminate period; “temporary” means limited periods but devoted exclusively to medical tasks during the whole of such periods.
Medical aircraft
7.22. Aircraft duly assigned to medical purposes, flying in combat zones are protected as soon as they are recognized as such. Medical aircraft flying over areas physically controlled by an adverse party, or over areas the control of which is not clearly established, may be ordered to land or to alight on water as appropriate to permit inspection. Medical aircraft must obey such orders. They must be given reasonable time for compliance but in default of such obedience the aircraft may be attacked. In all cases, protection for medical aircraft can be fully effective only by prior agreement between the competent military authorities of the parties to the conflict. 
United Kingdom, The Manual of the Law of Armed Conflict, Ministry of Defence, 1 July 2004, §§ 7.12–7.12.1 and 7.22.
In its chapter on air operations, the manual states:
12.28. The following classes of enemy aircraft are exempt from attack:
a. medical aircraft;
b. aircraft granted safe conduct by agreement between the parties to the conflict; and
c. civil airliners.
Conditions of exemption for medical aircraft
12.29. Medical aircraft are exempt from attack only if they:
a. have been recognized as such;
b. are acting in compliance with an agreement as specified in paragraph 12.112;
c. fly in areas under the control of own or friendly forces; or
d. fly outside the area of armed conflict.
12.29.1. In other instances, medical aircraft operate at their own risk.
Conditions of exemption for aircraft granted safe conduct
12.30. Aircraft granted safe conduct are exempt from attack only if they:
a. are innocently employed in their agreed role;
b. do not intentionally hamper the movements of combatants; and
c. comply with the details of the agreement, including availability for inspection.
Conditions of exemption for civil airliners
12.31. Civil airliners are exempt from attack only if they:
a. are innocently employed in their normal role; and
b. do not intentionally hamper the movements of combatants.
Loss of exemption
12.32. If aircraft exempt from attack breach any of the applicable conditions of their exemption as set forth in paragraphs 12.29 to12.31, they may be attacked only if:
a. diversion for landing, visit and search, and possible capture, is not feasible;
b. no other method is available for exercising military control;
c. the circumstances of non-compliance are sufficiently grave that the aircraft has become, or may be reasonably assumed to be, a military objective; and
d. the collateral casualties or damage will not be disproportionate to the military advantage gained or anticipated.
12.33. In case of doubt whether a vessel or aircraft exempt from attack is being used to make an effective contribution to military action, it shall be presumed not to be so used. 
United Kingdom, The Manual of the Law of Armed Conflict, Ministry of Defence, 1 July 2004, §§ 12.28–12.29.1 and 12.30–12.33.
The manual further states:
12.93. The following aircraft are exempt from capture:
a. medical aircraft; and
b. aircraft granted safe conduct by agreement between the parties to the conflict.
12.94. Aircraft listed in paragraph 12.93 are exempt from capture only if they:
a. are innocently employed in their normal role;
b. do not commit acts harmful to the enemy;
c. immediately submit to interception and identification when required;
d. do not intentionally hamper the movement of combatants and obey orders to divert from their track when required; and
e. are not in breach of a prior agreement. 
United Kingdom, The Manual of the Law of Armed Conflict, Ministry of Defence, 1 July 2004, §§ 12.93–12.94.
The manual defines medical aircraft as follows:
The term “medical aircraft” is defined as any means, whether service or civilian, of conveying by air the wounded, sick, shipwrecked, medical personnel, religious personnel, medical equipment or medical supplies protected by the Geneva Conventions and Additional Protocol I. Whether assigned on a permanent or temporary basis, such an aircraft must be assigned exclusively to that purpose and must be under the control of a competent authority of a party to the conflict. The term “shipwrecked” includes personnel in the sea or other waters after forced landing by or from aircraft. Helicopters used for medical purposes within the above conditions come within the definition of medical aircraft. Hovercraft do not. 
United Kingdom, The Manual of the Law of Armed Conflict, Ministry of Defence, 1 July 2004, § 12.104.
On the protection of medical aircraft, the manual states:
12.110. In and over land areas physically controlled by friendly forces, or in and over sea areas not physically controlled by an adverse party, the respect and protection of medical aircraft of a party to the conflict is not dependent on any agreement with an adverse party.
12.110.1. Where, however, proposed flight plans of medical aircraft will bring them within the range of an adverse party’s surface to air weapons systems it is only sensible for the party operating the aircraft to notify the adverse party. In any circumstances, specific agreement between the adversaries, and any other states involved, is, in practice, the most effective guarantee of the safety of medical aircraft.
Contact and similar zones
12.111. In and over those parts of the contact zone which are physically controlled by friendly forces and in and over those areas the physical control of which is not clearly established, protection for medical aircraft can only be effective in so far as this has been agreed in advance by the parties. In the absence of an agreement medical aircraft operate at their own risk but they must nevertheless be respected when recognized.
12.111.1. The “contact zone” is any area on land where the forward elements of opposing forces are in contact with each other, especially where they are exposed to direct fire from the ground.
Areas controlled by an adverse party
Prior agreement
12.112. Medical aircraft continue to be protected whilst flying over land or sea areas physically controlled by an adverse party so long as there are prior agreements to that effect. Parties to the conflict are encouraged to notify such flights and to conclude such agreements, particularly in areas where control is not clearly established. Agreements should specify the altitudes, times and routes for safe operation and should include means of identification and communications.
12.112.1. A medical aircraft which flies over an area physically controlled by an adverse party either without prior agreement or in breach of the terms of an agreement, either through navigational error or because of an emergency affecting the safety of the flight, must make every effort to identify itself and to inform the adverse party of the circumstances. As soon as a medical aircraft has been recognized by an adverse party, that party is to make all reasonable efforts to give the order to land or to alight on water for inspection, or to take other measures to safeguard its own interests. In any case, the aircraft concerned must be allowed time for compliance before it is attacked. It is likely that any such agreement would be for a specific flight or series of flights rather than a general agreement lasting for a period of time. The necessity for having an agreement and adhering rigidly to its terms cannot be over-stressed. A medical aircraft, no matter how well-marked and in how many ways it indicates its status, which enters enemy airspace without agreement or in breach of the terms of an agreement is at risk of attack even if it has been recognized as claiming medical status. Before attacking, an adverse party must make all reasonable efforts to give the order to land or alight on water for inspection. This obligation arises only where there has been navigational error or an emergency affecting the safety of the flight and the circumstances have been communicated to the adverse party.
Absence of prior agreement
12.113. Whether a belligerent orders a medical aircraft to land for inspection or takes other measures to safeguard its interests, for example, ordering a change of route, an increase in altitude or requesting more information about the nature of the medical aircraft’s difficulties, it must allow that aircraft time for compliance before attacking. The degree of deviation from an agreement or from instructions that an enemy may claim as justification for an attack might be very slight. The captain of a medical aircraft must take great care to ensure that his aircraft does not enter enemy airspace without prior agreement and that, when it does enter by agreement, that the terms of the agreement are closely adhered to. The captain of a medical aircraft who finds that his aircraft has strayed into enemy airspace must make every effort to identify his aircraft to the enemy and to indicate his submission to that adverse party’s air traffic instructions. If, owing to an emergency, it is necessary to enter enemy airspace without prior agreement or contrary to the terms of an agreement, contact should, if possible, be made with the enemy in order to obtain agreement to the proposed course of action.
Medical aircraft in neutral airspace
12.114. Belligerent medical aircraft shall not enter neutral airspace except by prior agreement. When within neutral airspace pursuant to agreement, medical aircraft shall comply with the terms of the agreement. The terms of the agreement may require the aircraft to land for inspection at a designated airport within the neutral state. Should the agreement so require, the inspection and follow-on action shall be conducted in accordance with paragraphs 12.115 to 12.116.
12.115. Should a medical aircraft, in the absence of an agreement or in deviation from the terms of an agreement, enter neutral airspace, either through navigational error or because of an emergency affecting the safety of the flight, it shall make every effort to give notice and to identify itself. Once the aircraft is recognised as a medical aircraft by the neutral state, it shall not be attacked but may be required to land for inspection. Once it has been inspected, and if it is determined in fact to be a medical aircraft, it shall be allowed to resume its flight.
12.116. If the inspection reveals that the aircraft is not a medical aircraft, it may be captured, and the occupants shall, unless agreed otherwise between the neutral State and the parties to the conflict, be detained in the neutral State where so required by the rules of international law applicable in armed conflict, in such a manner that they cannot again take part in the hostilities.
Summary of rules
12.117. The rules that must be observed by the captain of a medical aircraft in relation to overflight of the territory of an adverse party may be summarized as follows:
a. no overflying without agreement;
b. where there is an agreement, its terms must be adhered to strictly;
c. there must be no deviation from the terms of an agreement for any reason other than an emergency affecting the safety of the flight;
d. if there is accidental overflight, in the absence of an agreement, every effort must be made to contact the adverse party, to identify the aircraft, its status and the circumstances of its flight and to submit to the adverse party’s air traffic instructions;
e. if an emergency affecting the safety of a flight necessitates overflying without agreement or in breach of an agreement, every attempt must be made to inform the adverse party and to seek its agreement. If times does not permit this course of action, a medical aircraft may proceed but must identify itself and its status to the adverse party and must immediately notify the adverse party of the circumstances and proposed course of action; and
f. the adverse party’s instructions, including instructions to land, must be obeyed.
Interception of enemy medical aircraft
12.118. If there is no agreement concerning the operation of an apparent enemy medical aircraft and it fails to respond to instructions then, if it constitutes an immediate military threat and other methods of control are impracticable, it may be attacked. Similarly, an apparent medical aircraft may be attacked if it is beyond reasonable doubt that its claim to protection is unjustified or indeed if it initiates an attack.
12.118.1. Any attack on an enemy aircraft recognized as claiming medical status should be instituted only as a last resort. If a purported medical aircraft is not known to be engaged in any activity inconsistent with medical status and obeys the instructions of its interceptor, it must not be attacked even if there has been no prior agreement as to its activity. 
United Kingdom, The Manual of the Law of Armed Conflict, Ministry of Defence, 1 July 2004, §§ 12.110–12.118.1.
Regarding restrictions on the use of medical aircraft, the manual states:
12.119. Parties to an armed conflict must not use medical aircraft in an attempt to acquire a military advantage. Their presence must not be used in an attempt to render military objectives immune from attack.
12.119.1. For example, areas where medical aircraft are loaded or unloaded, including helicopter pads, should be as far away as practicable from areas of normal military operations. Medical aircraft should not be parked adjacent to buildings or other installations which themselves are not entitled to protection.
Intelligence
12.120. Medical aircraft must not be used to collect or transmit intelligence data or carry any equipment intended for such purposes. The persons and cargo that may be carried by medical aircraft are restricted to the wounded, sick, shipwrecked, medical and religious personnel and medical supplies. Personal effects and equipment intended solely to facilitate navigation, communication or identification are permissible.
12.120.1. The presence of communications and encryption equipment in an aircraft operating as a medical aircraft is not precluded. Nor is the use of such equipment wholly to facilitate navigation, identification and communication in support of the operation of medical aircraft. Neither such presence nor such use negates the protection to which the medical aircraft is entitled.
Arms
12.121. Medical aircraft must not carry any armament. However, small arms and ammunition collected from the wounded, sick and shipwrecked on board and not yet handed over to the proper service authority, together with such light individual weapons as may be necessary to enable medical personnel on the aircraft to defend themselves and the wounded, sick and shipwrecked in their charge, are permissible.
Search and rescue
12.122. Whilst flying over contact or similar zones or over areas controlled by an adverse party, medical aircraft must not, without prior agreement with the adverse party, be used to search for the wounded, sick and shipwrecked.
12.122.1. This restriction does not relate to the use of medical aircraft for such search purposes in areas controlled by friendly forces or not physically controlled by an adverse party. In these circumstances, the medical aircraft is, when recognized, entitled to protection.
12.122.2. An agreement to operate medical aircraft in a search and rescue role will be more readily achieved following a specific engagement when search and rescue is considered necessary. A speculative search and rescue operation when there are no known casualties is more likely to be construed as a reconnaissance exercise and an agreement is thus less likely to be achieved. 
United Kingdom, The Manual of the Law of Armed Conflict, Ministry of Defence, 1 July 2004, §§ 12.119–12.122.2.
[emphasis in original]
In a footnote to paragraph 12.120.1, the manual states:
On ratification of [the 1977 Additional Protocol I], the UK made the following statement: “given the practical need to make use of non-dedicated aircraft for medical evacuation purposes, the UK does not interpret this paragraph as precluding the presence on board of communications equipment and encryption materials or the use thereof solely to facilitate navigation, identification or communication in support of medical transportation”. 
United Kingdom, The Manual of the Law of Armed Conflict, Ministry of Defence, 1 July 2004, § 12.120.1, footnote 162.
Regarding the landing and inspection of medical aircraft, the manual states:
12.125. A medical aircraft flying over areas which are either physically controlled by an adverse party or over which physical control has not been clearly established may be ordered to land for inspection. Medical aircraft must obey such an order.
12.125.1. Whether a medical aircraft has landed in response to such an order or whether it has landed for other reasons, an inspection must be commenced without delay and must be conducted expeditiously. The party carrying out the inspection may not order the removal of the wounded and sick from the aircraft unless their removal is essential for the inspection. It must, in any event, ensure that the condition of the wounded and sick is not adversely affected by the inspection or the removal. Although there is no provision prohibiting the removal of crews, the medical attendants or medical supplies from the aircraft during the inspection, the inspection should be carried out as expeditiously as possible and with the minimum of inconvenience and should be carried out in a reasonable and unprovocative manner always bearing in mind the humanitarian mission of the aircraft involved.
Medical status confirmed
12.126. If the inspection discloses that an aircraft:
a. is a medical aircraft as defined in paragraph 12.104;
b. has not violated any of the restrictions set out in paragraphs 12.119–12.121 [relating to military advantage, intelligence, arms, and search and rescue]; and
c. has not flown without, or in breach of, a prior agreement where such an agreement is required …
the aircraft and those of its occupants who belong to the adverse party operating the aircraft or to a neutral state or other state which is not a party to the conflict must be allowed to continue the flight without further delay.
Medical status not confirmed
12.127. If, however, an inspection discloses that an aircraft:
a. is not a medical aircraft as defined in paragraph 12.104;
b. has violated any of the restrictions set out in paragraphs 12.119–12.121 [relating to military advantage, intelligence, arms, and search and rescue]; or
c. has flown without, or in breach of, a prior agreement where such an agreement is required …
the aircraft may be seized. A seized aircraft that has been assigned as a permanent medical aircraft may be used thereafter by the capturing power as, and only as, a medical aircraft. Each occupant of the aircraft is treated according to his status. 
United Kingdom, The Manual of the Law of Armed Conflict, Ministry of Defence, 1 July 2004, §§ 12.125–12.127.
United States of America
The US Field Manual (1956) restates Article 36 of the 1949 Geneva Convention I and adds:
It is not necessary that the aircraft should have been specially built and equipped for medical purposes. There is no objection to converting ordinary aircraft into medical aircraft or to using former medical aircraft for other purposes, provided the distinctive markings are removed. 
United States, Field Manual 27-10, The Law of Land Warfare, US Department of the Army, 18 July 1956, as modified by Change No. 1, 15 July 1976, § 237.
United States of America
The US Air Force Pamphlet (1976) states:
Generally, a medical aircraft (identified as such) should not be attacked unless under the circumstances at the time it represents an immediate military threat and other methods of control are not available. For example, this might occur when it approaches enemy territory or a combat zone without permission and disregards instructions, or initiates an attack. Attacks might also occur when the aircraft is not identified as a medical aircraft because of lack of agreement as to the height, time and route. 
United States, Air Force Pamphlet 110-31, International Law – The Conduct of Armed Conflict and Air Operations, US Department of the Air Force, 1976, § 4-2(f).
The Pamphlet further provides: “In addition to grave breaches of the Geneva Conventions of 1949, the following acts are representative of situations involving individual criminal responsibility: (1) deliberate attack on protected medical aircraft”. 
United States, Air Force Pamphlet 110-31, International Law – The Conduct of Armed Conflict and Air Operations, US Department of the Air Force, 1976, § 15-3(c)(1).
United States of America
The US Air Force Commander’s Handbook (1980) provides:
Medical aircraft, recognized as such, should not be deliberately attacked or fired on. Medical aircraft are not permitted to fly over territory controlled by the enemy, without the enemy’s prior agreement. Medical aircraft must comply with requests to land for inspection. Medical aircraft complying with such a request must be allowed to continue their flight, with all personnel on board, if inspection does not reveal that the aircraft has engaged in acts harmful to the enemy or otherwise violated the Geneva Conventions of 1949. 
United States, Air Force Pamphlet 110-34, Commander’s Handbook on the Law of Armed Conflict, Judge Advocate General, US Department of the Air Force, 25 July 1980, § 3-2(c).
United States of America
The US Naval Handbook (1995) qualifies “deliberate attack upon … medical aircraft” as a war crime. 
United States, The Commander’s Handbook on the Law of Naval Operations, NWP 1-14M/MCWP 5-2.1/COMDTPUB P5800.7, issued by the Department of the Navy, Office of the Chief of Naval Operations and Headquarters, US Marine Corps, and Department of Transportation, US Coast Guard, October 1995 (formerly NWP 9 (Rev. A)/FMFM 1-10, October 1989), § 6.2.5.
United States of America
The US Naval Handbook (2007) states that examples of war crimes that could be considered as grave breaches of the 1949 Geneva Conventions include: “Deliberate attacks upon … medical aircraft.” 
United States, The Commander’s Handbook on the Law of Naval Operations, NWP 1-14M/MCWP 5-12.1/COMDTPUB P5800.7, issued by the Department of the Navy, Office of the Chief of Naval Operations and Headquarters, US Marine Corps, and Department of Homeland Security, US Coast Guard, July 2007, § 6.2.6(7).
Yugoslavia, Socialist Federal Republic of
The Socialist Federal Republic of Yugoslavia’s Military Manual (1988) restates the rules on medical aircraft set out in Articles 25–28 of the 1977 Additional Protocol I. 
Yugoslavia, Socialist Federal Republic of, Propisi o Primeri Pravila Medjunarodnog Ratnog Prava u Oruzanim Snagama SFRJ, PrU-2, Savezni Sekretarijat za Narodnu Odbranu (Pravna Uprava), 1988, §§ 317–321.
Zimbabwe
Zimbabwe’s Code of Conduct for Combatants (1993) states: “Respect … medical aircrafts marked with Red Cross/Red Crescent/Red Crystal emblems.” 
Zimbabwe, Code of Conduct for Combatants, Joint publication of the Zimbabwe Defence Forces and the International Committee of the Red Cross Regional Delegation in Harare, 1993, p. 7.
Bangladesh
Bangladesh’s International Crimes (Tribunal) Act (1973) states that the “violation of any humanitarian rules applicable in armed conflicts laid down in the Geneva Conventions of 1949” is a crime. 
Bangladesh, International Crimes (Tribunal) Act, 1973, Section 3(2)(e).
Denmark
Denmark’s Military Criminal Code (1973), as amended in 1978, provides:
Any person who uses war instruments or procedures the application of which violates an international agreement entered into by Denmark or the general rules of international law, shall be liable to the same penalty [i.e. a fine, lenient imprisonment or up to 12 years’ imprisonment]. 
Denmark, Military Criminal Code, 1973, as amended in 1978, § 25(1).
Denmark’s Military Criminal Code (2005) provides:
Any person who deliberately uses war means [“krigsmiddel”] or procedures the application of which violates an international agreement entered into by Denmark or international customary law, shall be liable to the same penalty [i.e. imprisonment up to life imprisonment]. 
Denmark, Military Criminal Code, 2005, § 36(2).
Estonia
Under Estonia’s Penal Code (2001), “an attack against … a medical aircraft” is a war crime. 
Estonia, Penal Code, 2001, § 106.
Greece
Greece’s Military Penal Code (1995) provides for the protection of medical aircraft. 
Greece, Military Penal Code, 1995, Article 156.
Ireland
Ireland’s Geneva Conventions Act (1962), as amended in 1998, provides that any “minor breach” of the 1949 Geneva Conventions, including violations of Article 36 of the Geneva Convention I, and of the 1977 Additional Protocol I, including violations of Articles 25–27, is a punishable offence. 
Ireland, Geneva Conventions Act, 1962, as amended in 1998, Section 4(1) and (4).
Norway
Norway’s Military Penal Code (1902), as amended in 1981, provides:
Anyone who contravenes or is accessory to the contravention of provisions relating to the protection of persons or property laid down in … the Geneva Conventions of 12 August 1949 … [and in] the two additional protocols to these Conventions … is liable to imprisonment. 
Norway, Military Penal Code, 1902, as amended in 1981, § 108.
Somalia
Somalia’s Military Criminal Code (1963) states:
363. Where a commander fails to adopt measures to protect buildings, places or objects that must be respected. – 1. A penalty of military confinement for up to three years shall be imposed on a commander of attacking forces who fails to adopt the measures prescribed by law and by international agreements to ensure respect for:
(a) … medical aircraft that have been assigned to military use … where they are not at the same time being used for military purposes and have been designated by the distinctive signs specified in the international conventions, or have in some way been indicated in advance to the enemy, and are easily visible even from a great distance and at a high altitude;
375. Use of weapons against … medical … aircraft … Anyone who uses weapons against … medical aircraft assigned to military use … when, in accordance with the law and international agreements, they must be regarded as respected and protected, shall, unless the act constitutes a more serious offence, be punished by military confinement for not less than 10 years. 
Somalia, Military Criminal Code, 1963, Articles 363(1)(a) and 375.
South Africa
In 1987, in the Petane case, the Cape Provincial Division of South Africa’s Supreme Court dismissed the accused’s claim that the 1977 Additional Protocol I reflected customary international law. The Court stated:
The accused has been indicted before this Court on three counts of terrorism, that is to say, contraventions of s 54(1) of the Internal Security Act 74 of 1982. He has also been indicted on three counts of attempted murder.
The accused’s position is stated to be that this Court has no jurisdiction to try him.
… The point in its early formulation was this. By the terms of [the 1977 Additional] Protocol I to the [1949] Geneva Conventions the accused was entitled to be treated as a prisoner-of-war. A prisoner-of-war is entitled to have notice of an impending prosecution for an alleged offence given to the so-called “protecting power” appointed to watch over prisoners-of-war. Since, if such a notice were necessary, the trial could not proceed without it, Mr Donen suggested that the necessity or otherwise for giving such a notice should be determined before evidence was led. …
On 12 August 1949 there were concluded at Geneva in Switzerland four treaties known as the Geneva Conventions. …
South Africa was among the nations which concluded the treaties. … Except for the common art 3, which binds parties to observe a limited number of fundamental humanitarian principles in armed conflicts not of an international character, they apply to wars between States.
After the Second World War many conflicts arose which could not be characterised as international. It was therefore considered desirable by some States to extend and augment the provisions of the Geneva Conventions, so as to afford protection to victims of and combatants in conflicts which fell outside the ambit of these Conventions. The result of these endeavours was Protocol I and Protocol II to the Geneva Conventions, both of which came into force on 7 December 1978.
Protocol II relates to the protection of victims of non-international armed conflicts. Since the State of affairs which exists in South Africa has by Protocol I been characterised as an international armed conflict, Protocol II does not concern me at all.
The extension of the scope of art 2 of the Geneva Conventions was, at the time of its adoption, controversial. …
The article has remained controversial. More debate has raged about its field of operation than about any other articles in Protocol I. …
South Africa is one of the countries which has not acceded to Protocol I. Nevertheless, I am asked to decide, as I indicated earlier, as a preliminary point, whether Protocol I has become part of customary international law. If so, it is argued that it would have been incorporated into South African law. If it has been so incorporated it would have to be proved by one or other of the parties that the turmoil which existed at the time when the accused is alleged to have committed his offences was such that it could properly be described as an “armed conflict” conducted by “peoples” against a “ra[c]ist regime” in the exercise of their “right of self-determination”. Once all this has been shown it would have to be demonstrated to the Court that the accused conducted himself in such a manner as to become entitled to the benefits conferred by Protocol I on combatants, for example that, broadly speaking, he had, while he was launching an attack, distinguished himself from civilians and had not attacked civilian targets. …
… I am prepared to accept that where a rule of customary international law is recognised as such by international law it will be so recognised by our law.
To my way of thinking, the trouble with the first Protocol giving rise to State practice is that its terms have not been capable of being observed by all that many States. At the end of 1977 when the treaty first lay open for ratification there were few States which were involved in colonial domination or the occupation of other States and there were only two, South Africa and Israel, which were considered to fall within the third category of ra[c]ist regimes. Accordingly, the situation sought to be regulated by the first Protocol was one faced by few countries; too few countries in my view, to permit any general usage in dealing with armed conflicts of the kind envisaged by the Protocol to develop.
Mr Donen contended that the provisions of multilateral treaties can become customary international law under certain circumstances. I accept that this is so. There seems in principle to be no reason why treaty rules cannot acquire wider application than among the parties to the treaty.
Brownlie Principles of International Law 3rd ed at 13 agrees that non-parties to a treaty may by their conduct accept the provisions of a multilateral convention as representing general international law. …
I incline to the view that non-ratification of a treaty is strong evidence of non-acceptance.
It is interesting to note that the first Protocol makes extensive provision for the protection of civilians in armed conflict. …
In this sense, Protocol I may be described as an enlightened humanitarian document. If the strife in South Africa should deteriorate into an armed conflict we may all one day find it a cause for regret that the ideologically provocative tone of s 1(4) has made it impossible for the Government to accept its terms.
To my mind it can hardly be said that Protocol I has been greeted with acclaim by the States of the world. Their lack of enthusiasm must be due to the bizarre mixture of political and humanitarian objects sought to be realised by the Protocol. …
According to the International Review of the Red Cross (January/February 1987) No 256, as at December 1986, 66 States were parties to Protocol I and 60 to Protocol II, which, it will be remembered, deals with internal non-international armed conflicts. With the exception of France, which acceded only to Protocol II, not one of the world’s major powers has acceded to or ratified either of the Protocols. This position should be compared to the 165 States which are parties to the Geneva Conventions.
This approach of the world community to Protocol I is, on principle, far too half-hearted to justify an inference that its principles have been so widely accepted as to qualify them as rules of customary international law. The reasons for this are, I imagine, not far to seek. For those States which are contending with “peoples[’]” struggles for self-determination, adoption of the Protocol may prove awkward. For liberation movements who rely on strategies of urban terror for achieving their aims the terms of the Protocol, with its emphasis on the protection of civilians, may prove disastrously restrictive. I therefore do not find it altogether surprising that Mr Donen was unable to refer me to any statement in the published literature that Protocol I has attained the status o[f] customary international [law].
I have not been persuaded by the arguments which I have heard on behalf of the accused that the assessment of Professor Dugard, writing in the Annual Survey of South African Law (1983) at 66, that “it is argued with growing conviction that under contemporary international law members of SWAPO [South-West Africa People’s Organisation] and the ANC [African National Congress] are members of liberation movements entitled to prisoner-of-war status, in terms of a new customary rule spawned by the 1977 Protocols”, is correct. On what I have heard in argument I disagree with his assessment that there is growing support for the view that the Protocols reflect a new rule of customary international law. No writer has been cited who supports this proposition. Here and there someone says that it may one day come about. I am not sure that the provisions relating to the field of application of Protocol I are capable of ever becoming a rule of customary international law, but I need not decide that point today.
For the reasons which I have given I have concluded that the provisions of Protocol I have not been accepted in customary international law. They accordingly form no part of South African law.
This conclusion has made it unnecessary for me to give a decision on the question of whether rules of customary international law which conflict with the statutory or common law of this country will be enforced by its courts.
In the result, the preliminary point is dismissed. The trial must proceed. 
South Africa, Supreme Court, Petane case, Judgment, 3 November 1987, pp. 2–8.
South Africa
In 2010, in the Boeremag case, South Africa’s North Gauteng High Court stated:
In Petane, … Conradie J found that the provisions of [the 1977 Additional] Protocol I are not part of customary international law, and therefore are also not part of South African law.
Referring to the fact that in December 1986 only 66 of the 165 States party to the Geneva Conventions had ratified Protocol I, the Court [in Petane] stated:
This approach of the world community to Protocol I is, on principle, far too half-hearted to justify an inference that its principles have been so widely accepted as to qualify them as rules of customary international law. The reasons for this are, I imagine, not far to seek. For those States which are contending with “peoples[’]” struggles for self-determination, adoption of the Protocol may prove awkward. For liberation movements who rely on strategies of urban terror for achieving their aims the terms of the Protocol, with its emphasis on the protection of civilians, may prove disastrously restrictive. I therefore do not find it altogether surprising that Mr Donen was unable to refer me to any statement in the published literature that Protocol I has attained the status of customary international law.
Important changes with respect to certain aspects applicable at the time of Petane have taken place. The ANC [African National Congress] has become South Africa’s ruling party and in 1995 ratified Protocol I. The total number of States that have ratified it, is now … 162.
This last aspect forms the basis on which the First Respondent [the State] and the applicants agree that Protocol I forms part of customary international law as well as of South African law. As requested, this position is accepted for the purposes of the decision, without deciding on the matter.
Despite these changes, it remains debatable whether the provisions of Protocol I have become a part of South African law in this way.
The consensus of both parties to the conflict is required. See Petane … and Article 96 of Protocol I. …
Parliament’s failure to incorporate Protocol I into legislation in accordance with Article 231(4) of the Constitution in fact points to the contrary, and is indicative that the requirements of usus and/or opinio juris have not been met. See Petane. 
South Africa, North Gauteng High Court, Boeremag case, Judgment, 26 August 2010, pp. 21–22.
[footnotes in original omitted]
The Court also held:
If the [1977 Additional Protocol I] applies in South Africa as customary international law, the two requirements that form the basis of customary law must be met. It is arguable that the requirement of usus has been met by the vast number of States that have acceded or ratified it. By ratifying Protocol I the Republic of South Africa has indicated its intention to apply the Protocol, thereby fulfilling the requirement of opinio juris. 
South Africa, North Gauteng High Court, Boeremag case, Judgment, 26 August 2010, p. 66.
Egypt
At the CDDH, during a debate in Committee II on Article 32 of the draft Additional Protocol I (“Neutral or other States not parties to the conflict”), Egypt stated: “To attack a medical aircraft is a serious matter and it would be better to take all other possible action first.” 
Egypt, Statement at the CDDH, Official Records, Vol. XII, CDDH/II/SR. 58, 27 April 1976, p. 34, § 30.
Egypt
At the CDDH, commenting on Article 27 of the draft Additional Protocol I, Egypt stated: “For the protection of medical aircraft, prior agreement is absolutely necessary for aircraft to fly over contact or similar zones.” 
Egypt, Statement at the CDDH, Official Records, Vol. VI, CDDH/SR.39, 25 May 1977, p. 114.
France
The instructions given to the French armed forces for the conduct of Opération Mistral, simulating a military operation under the right of self-defence or a mandate of the UN Security Council, refer to Articles 25 and 27 of the 1977 Additional Protocol I. 
France, Etat-major de la Force d’Action Rapide, Ordres pour l’Opération Mistral, 1995, Section 6, § 62.
France
Upon ratification of the 1977 Additional Protocol I, France stated:
Given the practical need to use non-dedicated aircraft for medical evacuation missions, the Government of the Republic of France does not interpret paragraph 2 of Article 28 as precluding the presence on board of communication equipment and encryption material or the use thereof solely to facilitate navigation, identification or communication in support of a medical transportation mission as defined in Article 8. 
France, Reservations and declarations made upon ratification of the 1977 Additional Protocol I, 11 April 2001, § 5.
Japan
At the CDDH, Japan stated: “Flying over enemy occupied areas was still prohibited … if [it] occurred by force of urgent necessity, in the absence of an agreement, that constituted a violation of the Protocol.” 
Japan, Statement at the CDDH, Official Records, Vol. XI, CDDH/II/SR.47, 5 April 1975, pp. 528–529, § 22.
United Kingdom of Great Britain and Northern Ireland
Upon ratification of the 1977 Additional Protocol I, the United Kingdom declared with respect to Article 28(2):
Given the practical need to make use of non-dedicated aircraft for medical evacuation purposes, the United Kingdom does not interpret this paragraph as precluding the presence on board of communication equipment and encryption materials or the use thereof solely to facilitate navigation, identification or communication in support of medical transportation as defined in Article 8 (f). 
United Kingdom, Reservations and declarations made upon ratification of the 1977 Additional Protocol I, 28 January 1998, § (e).
United States of America
It is reported that in the Vietnam War, US army medical evacuation helicopters marked with the red cross emblem suffered a high loss rate from enemy fire, with the result that some medical evacuation units armed their helicopters with machine guns. 
Peter Dorland and James Nanney, Dust Off: Army Aeromedical Evacuation in Vietnam, Center of Military History, United States Army, Washington D.C., 1982, p. 85.
United States of America
In 1987, the Deputy Legal Adviser of the US Department of State affirmed: “We support the principle that known medical aircraft be respected and protected when performing their humanitarian functions.” He added: “That is a rather general statement of what is reflected in many, but not all, aspects of the detailed rules in Articles 24 through 31, which include some of the more useful innovations in the Protocol.” 
United States, Remarks of Michael J. Matheson, Deputy Legal Adviser, US Department of State, The Sixth Annual American Red Cross-Washington College of Law Conference on International Humanitarian Law: A Workshop on Customary International Law and the 1977 Protocols Additional to the 1949 Geneva Conventions, American University Journal of International Law and Policy, Vol. 2, 1987, p. 423–424.
United States of America
The Report on US Practice notes that US practice suggests that if enemy forces do not respect the protected status of medical units, the right of self-defence may justify the use of force. 
Report on US Practice, 1997, Chapter 2.7.
Yugoslavia, Socialist Federal Republic of
In 1991, in a document entitled “Examples of violations of the rules of international law committed by the so-called armed forces of Slovenia”, the Ministry of Defence of the Socialist Federal Republic of Yugoslavia included the following example: “Fire has been opened on medical helicopters and planes in spite of their Red Cross signs.” 
Yugoslavia, Socialist Federal Republic of, Minister of Defence, Examples of violations of the rules of international law committed by the so-called Armed Forces of Slovenia, 10 July 1991, § 1(iii).
UN Commission on Human Rights (Special Rapporteur)
In 1996, in a report on the situation of human rights in the Sudan, in a section entitled “Human rights violations – Abuses by parties to the conflict other than the Government of Sudan”, the Special Rapporteur of the UN Commission on Human Rights reported that an ICRC plane was shot at and hit when preparing for landing. Following the incident, the ICRC delegation was advised by its headquarters not to fly to certain areas. 
UN Commission on Human Rights, Special Rapporteur on the Situation of Human Rights in the Sudan, Report, UN Doc. E/CN.4/1996/62, 20 February 1996, § 78.
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ICRC
To fulfil its task of disseminating IHL, the ICRC has delegates around the world teaching armed and security forces the rules set out in Articles 25–28 of the 1977 Additional Protocol I. 
Frédéric de Mulinen, Handbook on the Law of War for Armed Forces, ICRC, Geneva, 1987, §§ 628–632.
ICRC
In a press release issued in 1993 in the context of the conflict in Angola, the ICRC denounced the destruction of one of its planes at Uige airport while waiting to evacuate 21 foreigners held by the União Nacional para Independência Total de Angola (UNITA). It called on the parties to comply with IHL and regarded the attack as a serious breach of the principles of IHL concerning respect for the red cross emblem. 
ICRC, Press Release No. 1737, Angola: Solemn ICRC Appeal, 10 February 1993.
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