Aviation Safety
Improved Data Collection Needed for Effective Oversight of Air Ambulance Industry Gao ID: GAO-07-353 February 21, 2007Air ambulance transport is widely regarded as improving the chances of survival for trauma victims and other critical patients. However, in recent years, the number of air ambulance accidents has led to increased industry scrutiny by government agencies, the public, the media, and the industry itself. The Federal Aviation Administration (FAA), which provides safety oversight, has been called upon by the National Transportation Safety Board (NTSB) and others to issue more stringent safety requirements for the industry. GAO's study addressed (1) recent trends in the air ambulance industry, (2) FAA's challenges in providing safety oversight, and (3) FAA's efforts to address the challenges and what is known about the effects of these efforts. To address these issues, we analyzed FAA, NTSB, and industry data, interviewed federal and industry officials, and conducted five site visits, among other things.
From 1998 to 2005, the air ambulance industry grew, largely in stand-alone (independent) operations, and experienced an increased number of accidents, resulting in added industry efforts to improve safety. Although there are few data on the industry's basic aspects, available data show increased numbers of helicopters and base stations between 2003 and 2005. Most of the base-station growth has been at airports and stand-alone helipads rather than hospital-based locations, a strong indication of the shift to stand-alone operations. The annual number of accidents increased from 1998 to 2003 but declined in 2004 and 2005. The decline may reflect added industry safety efforts, such as the creation of a study group that recommends best practices. However, the lack of actual flight-hour data prevents calculation of the industry's accident rate, making it difficult to determine whether the industry has become more or less safe. FAA's main challenge in providing safety oversight for air ambulances is that its oversight approach is not geared toward air ambulance operations. For example, FAA uses the same set of regulations to oversee air ambulance operations as it uses to oversee other air taxi services. Air ambulance flights are subject to greater risks than other helicopter operations because they often fly at night, in a variety of weather conditions, and to remote sights to provide medical attention. These transports also can involve multiple medical and aviation officials, increasing the potential for human error. The broad nature of the applicable regulations further inhibits FAA oversight because they may not fully address the potential risks air ambulance operations face. FAA has initiated many efforts to strengthen its oversight of air ambulances but does not evaluate the effectiveness of its efforts. FAA's efforts include establishing a task force to review air ambulance accidents, plans for hiring additional staff to oversee large operators, and issuing guidance to inspectors and operators promoting various safety practices. However, FAA does not track implementation of its voluntary guidance. Also, FAA cannot measure basic industry trends, such as accident rate changes. Measuring these trends requires actual flight-hour data, which FAA does not currently collect. Without this data, FAA cannot know if its efforts are achieving their intended results.
RecommendationsOur recommendations from this work are listed below with a Contact for more information. Status will change from "In process" to "Open," "Closed - implemented," or "Closed - not implemented" based on our follow up work.
Director: Team: Phone:GAO-07-353, Aviation Safety: Improved Data Collection Needed for Effective Oversight of Air Ambulance Industry
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Report to the Chairman, Subcommittee on Aviation, Committee on
Transportation and Infrastructure, House of Representatives:
United States Government Accountability Office:
GAO:
February 2007:
Aviation Safety:
Improved Data Collection Needed for Effective Oversight of Air
Ambulance Industry:
GAO-07-353:
GAO Highlights:
Highlights of GAO-07-353, a report to the Chairman, Subcommittee on
Aviation, Committee on Transportation and Infrastructure, House of
Representatives
Why GAO Did This Study:
Air ambulance transport is widely regarded as improving the chances of
survival for trauma victims and other critical patients. However, in
recent years, the number of air ambulance accidents has led to
increased industry scrutiny by government agencies, the public, the
media, and the industry itself. The Federal Aviation Administration
(FAA), which provides safety oversight, has been called upon by the
National Transportation Safety Board (NTSB) and others to issue more
stringent safety requirements for the industry.
GAO‘s study addressed (1) recent trends in the air ambulance industry,
(2) FAA‘s challenges in providing safety oversight, and (3) FAA‘s
efforts to address the challenges and what is known about the effects
of these efforts. To address these issues, we analyzed FAA, NTSB, and
industry data, interviewed federal and industry officials, and
conducted five site visits, among other things.
What GAO Found:
From 1998 to 2005, the air ambulance industry grew, largely in stand-
alone (independent) operations, and experienced an increased number of
accidents, resulting in added industry efforts to improve safety.
Although there are few data on the industry‘s basic aspects, available
data show increased numbers of helicopters and base stations between
2003 and 2005. Most of the base-station growth has been at airports and
stand-alone helipads rather than hospital-based locations, a strong
indication of the shift to stand-alone operations. The annual number of
accidents increased from 1998 to 2003 but declined in 2004 and 2005.
The decline may reflect added industry safety efforts, such as the
creation of a study group that recommends best practices. However, the
lack of actual flight-hour data prevents calculation of the industry‘s
accident rate, making it difficult to determine whether the industry
has become more or less safe.
FAA‘s main challenge in providing safety oversight for air ambulances
is that its oversight approach is not geared toward air ambulance
operations. For example, FAA uses the same set of regulations to
oversee air ambulance operations as it uses to oversee other air taxi
services. Air ambulance flights are subject to greater risks than other
helicopter operations because they often fly at night, in a variety of
weather conditions, and to remote sights to provide medical attention.
These transports also can involve multiple medical and aviation
officials, increasing the potential for human error. The broad nature
of the applicable regulations further inhibits FAA oversight because
they may not fully address the potential risks air ambulance operations
face.
FAA has initiated many efforts to strengthen its oversight of air
ambulances but does not evaluate the effectiveness of its efforts.
FAA‘s efforts include establishing a task force to review air ambulance
accidents, plans for hiring additional staff to oversee large
operators, and issuing guidance to inspectors and operators promoting
various safety practices. However, FAA does not track implementation of
its voluntary guidance. Also, FAA cannot measure basic industry trends,
such as accident rate changes. Measuring these trends requires actual
flight-hour data, which FAA does not currently collect. Without this
data, FAA cannot know if its efforts are achieving their intended
results.
Figure: Air Ambulance Helicopter:
[See PDF for Image]
Source: Clare McLean 2006.
[End of figure]
What GAO Recommends:
GAO recommends that FAA (1) identify the data necessary to better
understand the air ambulance industry and develop a systematic approach
for gathering and using this data and (2) collect information to
evaluate the effectiveness of voluntary FAA guidance. DOT agreed with
our findings and conclusions, and agreed to consider our
recommendations.
[Hyperlink, http://www.gao.gov/cgi-bin/getrpt?GAO-07-353].
To view the full product, including the scope and methodology, click on
the link above. For more information, contact Gerald L. Dillingham,
Ph.D., at (202) 512-2834 or dillinghamg@gao.gov.
[End of figure]
Contents:
Letter:
Results in Brief:
Background:
Increase in Size and Safety-Related Concerns Mark Industry's Recent
Years:
FAA Safety Oversight Does Not Fully Address Industry's Operational
Risks:
FAA Efforts to Improve Safety Are Under Way, but Effects Are Not Being
Measured:
Conclusions:
Recommendations for Executive Action:
Agency Comments and Our Evaluation:
Appendix I: Scope and Methodology:
Appendix II: NTSB Air Ambulance Accident Data:
Appendix III: Comments from the Association of Air Medical Services:
Appendix IV: GAO Contact and Staff Acknowledgments:
Tables:
Table 1: Examples of Independent and Hospital-Based Operators:
Table 2: Examples of Air Ambulance Industry Initiatives to Address
Safety Concerns:
Table 3: Key FAA Published Efforts to Improve Air Ambulance Safety:
Table 4: NTSB Recommendations and FAA Responses:
Table 5: Industry and Trade Organizations Interviewed:
Table 6: Description of States Selected for Site Visits:
Table 7: NTSB Air Ambulance Accident Information, 1998 through 2005:
Figures:
Figure 1: Air Ambulance Helicopter:
Figure 2: Helicopter Air Ambulance Service Locations:
Figure 3: Air Ambulance Scene Response Flight Legs:
Figure 4: Annual Air Ambulance Bases and Aircraft, 2003 to 2005:
Figure 5: Number of Hospital-Based and Airport and Helipad Air
Ambulance Bases, 2003 to 2005:
Figure 6: Total Air Ambulance Accidents, 1998 to 2005:
Figure 7: Time of Day of Air Ambulance Fatal and Nonfatal Accidents,
1998 to 2005:
Figure 8: Percentage of Air Ambulance and Other Helicopter Accidents
Associated with Adverse Weather, 1998 to 2005:
Abbreviations:
AAMS: Association of Air Medical Services:
AMPA: Air Medical Physician Association:
AMSAC: Air Medical Safety Advisory Council:
CAMTS: Commission on the Accreditation of Medical Transport Systems:
CUBRC: Calspan-University of Buffalo Research Center:
DOT: Department of Transportation:
FAA: Federal Aviation Administration:
FARE: Foundation for Air Medical Research and Education:
GAATAA: General Aviation and Air Taxi Activity and Avionics survey:
HEMS: Helicopter Emergency Medical Services:
NTSB: National Transportation Safety Board:
PHI: Petroleum Helicopters International:
SEP: Surveillance and Evaluation Program:
United States Government Accountability Office:
Washington, DC 20548:
February 21, 2007:
The Honorable Jerry F. Costello:
Chairman:
Subcommittee on Aviation:
Committee on Transportation and Infrastructure:
House of Representatives:
Dear Mr. Chairman:
The image of a helicopter air ambulance landing at a hospital or on the
side of a highway--a familiar sight on television news--is an
indication of the degree to which such ambulances are now a part of the
nation's medical system. Air ambulance transportation is widely
regarded as having a beneficial impact on improving the chances of
survival and recovery for trauma victims and other critical patients,
particularly in rural areas that lack readily accessible advanced-care
facilities and medical specialists. Medical theory and practice hold
that providing critically injured patients with surgical intervention
within the first hour after injury occurs--a time period referred to by
some as the "golden hour" --can significantly improve chances for
survival and recovery. Air ambulance helicopters, with their ability to
land at accident sites and quickly shuttle to landing areas at or near
hospitals, can reduce transport times for many patients.
Figure 1: Air Ambulance Helicopter:
[See PDF for Image]
Source: Clare McLean 2006.
[End of section]
Air ambulance operations, however, can also be risky. Challenging
flight conditions such as flying at night and into unfamiliar landing
sites, within the critical window for medical intervention, makes these
flights inherently more risky than those conducted by other
helicopters. In recent years, the number of air ambulance accidents has
led to increased scrutiny of the industry by government agencies, the
public, the media, and the industry itself. In addition, the Federal
Aviation Administration (FAA), the federal agency responsible for
providing safety oversight, has been asked by the National
Transportation Safety Board (NTSB) and others to issue more stringent
safety requirements for the industry.
In response to your request, we examined the safety issues facing the
industry and FAA's safety oversight. Specifically, we addressed the
following questions: (1) What have been the recent trends in the air
ambulance industry with regard to size, composition, and safety record?
(2) What challenges does FAA face in providing safety oversight of the
air ambulance industry? and (3) What efforts does FAA have under way to
address any oversight challenges, and what is known about the effects
of these efforts? To address these questions, we analyzed NTSB, FAA,
and industry data; conducted an extensive literature review; and
interviewed FAA and NTSB officials, as well as industry experts and
representatives from key industry associations and air ambulance
operators. In addition, we conducted site visits to five states that
had multiple air ambulance operators with a diversity of business
models operating in proximity to one another. During these site visits,
we interviewed representatives of air ambulance service providers and
officials from local FAA flight standards district offices. We also
visited operator facilities and observed a number of elements of
operations. This report focuses on the aviation safety aspects of
commercial helicopter air ambulances; the scope of our study did not
include analysis of the appropriateness of associated costs, payments,
or medical utilization of air ambulance transportation. We conducted
our review from April 2006 through January 2007 in accordance with
generally accepted government auditing standards. More details
regarding our scope and methodology can be found in appendix I.
Results in Brief:
The air ambulance industry has experienced recent growth, primarily in
stand-alone (independent) operations, and an increase in the number of
accidents, resulting in increased efforts to make safety-related
improvements. There is limited or incomplete data available on basic
aspects of the industry, including the number of air ambulance
helicopters and the number of hours flown by air ambulances. Although
data limitations preclude a complete understanding of the industry,
including its growth, available data for 2003 to 2005 show the number
of helicopters involved exclusively in air ambulance operations
increased 38 percent (from 545 to 753), while the number of locations
from which they operate grew by 30 percent (from 472 to 614).
Similarly, although data are not available on the number of stand-alone
and hospital-based operators, most of the growth in operating locations
since 2003 has been in airports and stand-alone helipads rather than
hospital-based locations. This is a strong indication of the movement
toward stand-alone operations. Industry sources indicate that this
growth has produced more competition in certain areas and potentially
led to such unsafe practices as "helicopter shopping"--a continued
search for air ambulance service by emergency medical service
dispatchers until an operator agrees to accept a flight. We identified
a total of 89 air ambulance accidents from 1998 to 2005 that resulted
in 75 fatalities and 31 serious injuries. These 89 accidents represent
nearly 40 percent of the total air ambulance accidents since 1972. The
annual number of accidents involving air ambulances tripled from 6 to
18 from 1998 to 2003 but has since declined to 12 and 11 in 2004 and
2005, respectively. This number remains above the levels of the 1980s,
but the drop in the past two years may reflect increased safety efforts
by the industry. These efforts include the creation of a study group
that recommends practices for operators to follow and the
implementation of various training programs. However, the lack of data
about the number of flights or flight hours precludes the calculation
of the industry's accident rate, making it difficult to determine
whether the industry is becoming more or less safe.
FAA's main challenge in providing safety oversight for air ambulances
is that its oversight approach is not geared toward air ambulance
helicopter operations, but rather to other segments of the aviation
industry that do not share many of the same operating characteristics
and risks. To oversee air ambulance operations, FAA uses a set of
regulations--Part 135--that it also uses to oversee air taxi services
and other on-demand operations. Unlike these other operators, air
ambulances provide urgent medical transport often by flying to remote
scenes, landing at ad-hoc prepared sites, and operating at all times of
day in a variety of weather conditions. Further, air ambulance
transport can involve emergency medical service dispatchers, crew
members, and others, underscoring the role of human factors before and
during a transport. Available data confirm that air ambulance accidents
are often related to their unique operating environment. For example,
fatal crashes involving air ambulances occur most often at night, and
air ambulance helicopters are four times more likely to have weather-
related crashes than helicopters used by other operators flying under
the same set of regulations. Our work showed that FAA inspectors may
not have the necessary expertise to certify some safety technology for
implementation by air ambulance operators. Inspectors also have limited
opportunities to review the air ambulance operations at the many remote
base stations of large operators due to a lack of time and resources.
The broad nature of Part 135 regulations further inhibits FAA safety
oversight, as requirements within these regulations may not fully
address the risks inherent to air ambulance operations.
FAA has a number of efforts under way to strengthen its oversight of
air ambulance operators, but it has not developed ways to evaluate the
effectiveness of these efforts. FAA's efforts include establishing a
task force to review air ambulance accidents, conducting various
meetings with industry officials, and devoting additional staff
resources to overseeing the largest operators. Another effort involves
issuing guidance to FAA inspectors and air ambulance operators to
enhance air ambulance safety. This new guidance has covered such
matters as reviewing pilots' and mechanics' adherence to procedures,
promoting risk management, and emphasizing certain aspects of safety.
Although the guidance has been voluntary to date, FAA has not ruled out
future regulatory action. While FAA inspectors are required to promote
the safety actions outlined in the guidance to air ambulance operators,
FAA has no plans for tracking the degree to which operators are
voluntarily implementing the guidance. FAA's ability to assess its
efforts is limited not only because it does not know the extent of
operators' implementation of the guidance but also because it cannot
accurately measure basic trends in the industry, such as changes in the
accident rate. Measuring these trends requires reliable data about
actual flight hours--data FAA does not currently have. Without this
data, FAA cannot know if it is targeting the appropriate amount of
agency resources to air ambulance oversight or whether its efforts are
achieving their intended results. Our discussions with air ambulance
operators indicated that flight-hour information is available and that
operators are willing to share it with FAA.
To help FAA monitor industry growth trends, accident rates, and
operator implementation of FAA guidance, we are recommending that the
Secretary of Transportation direct the Administrator of FAA to (1)
identify the data necessary to better understand the air ambulance
industry and develop a systematic approach for gathering and using this
data, and (2) collect information to evaluate the effectiveness of
voluntary FAA guidance. We provided the Department of Transportation
(DOT) and NTSB with a draft copy of this report for their review and
comment. DOT agreed with our findings and conclusions, and agreed to
consider our recommendations. NTSB agreed with our findings,
conclusions, and recommendations. Both agencies provided technical
comments, which were incorporated, as appropriate. We also provided the
Association of Air Medical Services (AAMS) with a draft of this report
to review, and AAMS agreed with our recommendations.
Background:
Air Ambulance Operations Perform Various Duties and Take Several Forms:
Air ambulance use in the United States began on a small scale in the
early 1970s, after use of air evacuation for wounded troops was
demonstrated to be an effective means of reducing combat mortality both
in the Korean and Vietnam wars. Air ambulances currently perform a
number of functions. Although most people may associate an air
ambulance with an on-scene response to an accident, the majority of
transports--about 54 percent--are from hospital to hospital. On-scene
responses make up another 33 percent, and the remaining 13 percent of
transports include organ, medical supply, and specialty medical team
transports. Air ambulances are of two main types--helicopters and fixed-
wing aircraft. These two types of aircraft are generally used on
different types of missions, with helicopters providing on-scene
responses and much of the shorter distance hospital-to-hospital
transport, and fixed-wing aircraft providing longer hospital-to-
hospital transports between airports. Helicopter air ambulances make up
more than 80 percent of the air ambulance fleet and, unlike fixed-wing
aircraft, do not always operate under the direction of FAA air traffic
controllers. This report concentrates on safety oversight issues
related to helicopter air ambulances.
Air ambulances are an integrated part of emergency medical systems
throughout the United States, and the market is dominated by a few
large operators. For example, it has been estimated that the top seven
operators operate nearly 80 percent of helicopter air ambulances.
Before commencing air ambulance flights, an operating certificate must
be obtained from FAA.[Footnote 1] FAA issues the certificate after
determining that an operator's manuals, aircraft, facilities, and
personnel meet federal safety standards. FAA subsequently monitors the
operator, primarily through safety inspections, to ensure that an
operator continues to meet the terms of its certificate. Air ambulance
operators often operate multiple air ambulance programs from a variety
of satellite base stations at hospitals, airports, or helipads in other
locations.[Footnote 2] Figure 2 shows base locations of helicopter air
ambulance services that perform on-scene transports.
Figure 2: Helicopter Air Ambulance Service Locations:
[See PDF for Image]
Sources: Atlas and Database of Air Medical Services (ADAMS); compiled
by CUBRC's Center for Transportation Injury Research (CenTIR) in
alliance with the Association of Air Medical Services (AAMS) with
support from the Federal Highway Administration (FHWA) and National
Highway Traffic Safety Administration (NHTSA); composite map by GAO.
[End of figure]
Air ambulance operations can take many different forms but are
generally one of two types--hospital-based or stand-alone:[Footnote 3]
* In a hospital-based model, a hospital typically provides the medical
services and staff and contracts with an aviation services provider for
pilots, mechanics, and aircraft. The aviation services provider also
holds the FAA operating certificate. In the hospital-based model, the
hospital is responsible for billing the patient and pays the operator
on a fixed monthly and variable hourly rate for services
provided.[Footnote 4]
* In a stand-alone (independent) provider model, an independent
operator sets up a base in a community and serves various facilities
and localities. Typically, the operator holds the FAA operating
certificate and employs both the medical and flight crews, or contracts
with an aviation services provider for all of these things. Compared
with the hospital-based model, this approach carries more financial
risk for the operator because revenues depend solely on patient
flights.
Table 1 illustrates the differences in these business models by
providing information on two of the operators we visited.
Table 1: Examples of Independent and Hospital-Based Operators:
Characteristic: Program;
Independent operator: Petroleum Helicopters International Air Medical;
Hospital-based operator: Teddy Bear Transport; Cook Children's Medical
Center.
Characteristic: Holder and location of FAA operating certificate;
Independent operator: Petroleum Helicopters International (PHI);
Lafayette, Louisiana; Hospital-based operator: CJ Systems; Harrisburg,
Pennsylvania.
Characteristic: Number of bases;
Independent operator: 49;
Hospital- based operator: 1.
Characteristic: Location of bases;
Independent operator: 14 states;
Hospital-based operator: Fort Worth, Texas.
Characteristic: Number of helicopters;
Independent operator: 224;
Hospital-based operator: 1.
Characteristic: Tax status;
Independent operator: For profit;
Hospital- based operator: Nonprofit.
Characteristic: Flight crew employer;
Independent operator: PHI;
Hospital-based operator: CJ Systems.
Characteristic: Medical crew employer;
Independent operator: PHI;
Hospital-based operator: Cook Children's Medical Center.
Characteristic: Revenue sources;
Independent operator: Per-flight basis;
Hospital-based operator: Patient flights, hospital admission.
Characteristic: Mission profile;
Independent operator: 50% on-scene 50% hospital-to-hospital;
Hospital-based operator: 100% hospital-to- hospital.
Source: GAO.
[End of table]
Government and Industry Both Play a Role in Air Ambulance Oversight:
All levels of the government and the air ambulance industry play
significant roles in air ambulance oversight. FAA has oversight over
commercial aviation activities performed by air carrier operators, a
group that includes operators of air ambulances. FAA's air ambulance
safety oversight is carried out by inspectors located in FAA field
offices throughout the United States that are a part of nine regional
offices. For each operating certificate, FAA puts together a team of
inspectors (also known as the certificate management team), led by
principal inspectors, who focus on one of three disciplines: avionics,
maintenance, or operations. Since 1985, FAA has used the National
Flight Standards Work Program Guidelines, its traditional inspection
program for airlines, as a primary means of ensuring air ambulance
operator compliance with safety regulations. Under the National Flight
Standards Work Program Guidelines, an FAA committee identifies an
annual minimum set of required inspections that are to be undertaken.
In addition, inspectors determine annual sets of planned inspections
based on their knowledge and experience with the particular operator
they oversee. When violations of statutory and regulatory requirements
are identified through inspections, FAA has a variety of enforcement
tools that it may use to respond to the violations, including
administrative and legal sanctions.
Under FAA regulation, most air ambulances operate under rules specified
in Part 135 of Title 14 of the Code of Federal Regulations.[Footnote 5]
However, pilots may operate under different standards, depending on
whether they are carrying patients. Without patients or passengers on
board, pilots may operate under rules specified in Part 91 of Title
14.[Footnote 6] These flights are considered "positioning" flights and
occur when flying to an accident scene or after having transported the
patient to the hospital or other destination. Medical personnel are
often on board for these flights, as they are considered part of the
crew rather than passengers. With patients on board, pilots are
required to operate under Part 135 rules.
Part 91 and Part 135 flight rules differ significantly in two key
areas--(1) weather and visibility minimums and (2) rest requirements--
with Part 135 requirements being more stringent. Under Part 91, the
basic weather minimum requirements for visual flight rules only state
that helicopters operate "clear of clouds" if flying under 1,200 feet
in uncontrolled (Class G) airspace and that the pilot must have
"adequate opportunity to see any air traffic or obstruction in time to
avoid a collision." This does not impose any specific flight visibility
distance on the pilot. In contrast, Part 135 requires that helicopter
operators flying under 1,200 feet have visibility of at least a half
mile during the day and at least one mile at night. This is the only
situation in which Part 91 weather minimums for visual flight rules are
lower than Part 135. Additionally, Part 135 requires that all
helicopter operators have visual surface reference during the day and
visual surface light reference at night. The other key difference
between Part 91 and Part 135 is the imposition of rest requirements on
pilots. Part 91 neither contains requirements for pilots to rest prior
to their flights nor prescribes a maximum duty time. Part 135, on the
other hand, requires helicopter pilots conducting emergency medical
operations to have adequate rest periods before and after their
flights, and it also contains restrictions on the number of consecutive
hours that pilots may fly.[Footnote 7]
In many air ambulance trips, part of the trip may involve Part 135
rules, while another part may involve Part 91 rules. Scene response
missions for air ambulance helicopters frequently have three legs: the
flight en route to the accident scene, the transport of the patient to
the hospital, and the repositioning of the helicopter back to its base
(see fig. 3). Of these three flight legs, only the leg during which
patients or other passengers (medical crew are not considered
passengers) are on board must be flown under Part 135 flight rules.
Because air ambulance flights without patients or passengers could be
flown under Part 91 requirements, there may be more than twice as many
flights taking place under Part 91 compared with Part 135.
Figure 3: Air Ambulance Scene Response Flight Legs:
[See PDF for Image]
Source: GAO.
[End of figure]
NTSB also plays a role in monitoring the safety issues related to the
air ambulance industry. As an independent federal agency charged by
Congress with investigating every aviation accident in the United
States, NTSB conducts investigations of air ambulance accidents and
develops factual reports containing determinations of probable cause
for these accidents. In January 2006, NTSB published a special report
focusing on emergency air medical operations, which included an
identification of recurring safety issues in air ambulance accidents
and subsequent recommendations for improving safety in the
industry.[Footnote 8] Additionally, in 1988, in response to an
increased number of accidents in the mid-1980s, NTSB published a safety
study that examined similar issues. The study contained 19 safety
recommendations to FAA and others, which have since been addressed,
according to NTSB.[Footnote 9]
Some state and local governments play a role in oversight of the air
ambulance industry, as well. The federal Airline Deregulation Act of
1978 explicitly prohibits states from regulating the price, route, or
service of an air carrier; therefore, oversight at the state or local
levels is generally limited to the medical care and equipment of air
ambulance services. The extent of this oversight, however, varies by
state and locality. Some states have not developed a regulatory
framework to oversee the medical care side of air ambulance services.
Other states do provide some oversight; California, for example,
delegates authority to local governments for emergency medical service
coordination and requires air ambulance providers to obtain a permit
from any county in which they routinely operate, irrespective of where
the provider is based. Still others, such as Maryland, Texas,
Washington, and Arizona, require state licensure of all air ambulance
service providers.
The industry also plays a role in its own oversight. One such industry-
driven activity is the accreditation offered by the Commission on
Accreditation of Medical Transport Systems (CAMTS), a 16-member
organization that provides voluntary accreditation for medical
transport systems, including air ambulances. Over 120 air ambulance
providers have earned CAMTS accreditation since its inception in 1991,
and five states have made CAMTS accreditation mandatory for all air
ambulance providers wishing to operate within their jurisdiction. CAMTS
places an overarching emphasis on patient care and transport safety,
with specific accreditation standards focusing on aircraft maintenance
and use as well as the medical, communications, and management aspects
of operation. Industry trade groups also play an informal role in
oversight. Industry groups, including the Association of Air Medical
Services, Helicopter Association International, the Air Medical
Physician's Association, and the National EMS Pilots Association,
devote much of their attention to information sharing regarding
operational challenges and best practices within the industry,
organizing conferences, and publishing white papers in order to place a
continued emphasis on safety.
Increase in Size and Safety-Related Concerns Mark Industry's Recent
Years:
Since 1998, the air ambulance industry has been characterized by
growth, an increased number of accidents, and various efforts to make
operations safer. Growth, according to industry officials and the
limited data available, has occurred mainly in stand-alone for-profit
operations rather than nonprofit hospital-based programs. For much of
this expansion period, the number of accidents also rose, peaking at 18
in 2003. During the 8-year period we examined (1998 through 2005), 89
air ambulance accidents occurred, but a lack of data about the number
of flights or hours flown prohibits us from calculating whether the
rate of accidents has increased, decreased, or remained the same over
this period. The 89 accidents represent nearly 40 percent of all air
ambulance industry accidents since 1972. Thirty-one of these accidents
resulted in fatalities, and 9 others resulted in serious injuries to
people on board. To address these developments, the air ambulance
industry has been encouraging greater safety among its operators
through such steps as conferences, additional training, and safety
awareness programs.
Data Limitations Preclude Complete Understanding of Industry's Growth:
Although industry experts and observers acknowledge the recent growth
of the air ambulance industry, the available data make it difficult to
gauge clearly the extent of the growth. Several years of data on two
indicators--number of aircraft and number of operating locations--are
available in a database maintained by the Calspan-University of Buffalo
Research Center (CUBRC) in alliance with AAMS.[Footnote 10] For 2003,
the first year of the database, association members reported a total of
545 helicopters stationed at 472 bases (airports, hospitals, and
helipads).[Footnote 11] By 2005, the number of helicopters listed in
the database had grown to 753, an increase of 38 percent, and the
number of bases had grown to 614, an increase of 30 percent (see fig.
4). A database official said that to some degree, the increase reflects
a broadening of the criteria for inclusion as well as better reporting
since the database was first established, but the increase also
reflected actual growth, which is similar to anecdotal information
relayed to us by air ambulance operators. For example, officials from
two large operators told us that their companies had added bases or
aircraft in the last few years. FAA maintains records of the number of
air ambulance operator aircraft currently in operation but does not
distinguish a company's dedicated air medical aircraft from its other
aircraft. FAA does estimate the number of air medical aircraft based on
its annual General Aviation and Air Taxi Activity and Avionics (GAATAA)
survey, and according to available estimates, there were 435 air
medical helicopters in 1999 and 741 in 2004, an increase of 70
percent.[Footnote 12] It is difficult to regard these estimates as
reliable, however, because the survey is based on a sample of aircraft
owners and has historically experienced low response rates.
Figure 4: Annual Air Ambulance Bases and Aircraft, 2003 to 2005:
[See PDF for Image]
Source: Association of Air Medical Services, Atlas and Database of Air
Medical Services.
[End of figure]
Data are less available on whether this increase in aircraft translates
into an increased number of operating hours. FAA does not collect
flight-hour data from air ambulance operators. Unlike scheduled air
carriers, which are required to report flight hours, air ambulance
operators and other types of on-demand operations regulated under Part
135 are not required to report flight activity data to FAA or
DOT.[Footnote 13] FAA does develop estimates of these flight hours,
using responses to its annual GAATAA survey. FAA estimated that air
ambulances amassed about 900,000 flight hours annually from 1999 to
2003 and that the number of flight hours increased to 1.6 million in
2004. However, as noted, the reliability of these estimates is
questionable, given various shortcomings with the GAATAA
survey.[Footnote 14] Other studies have shown flight-hour estimates
that are much lower than FAA estimates. For example, a study sponsored
by the Air Medical Physician Association (AMPA) has also estimated
annual flight hours for the air medical industry. To determine flight
hours, the study's authors posted a survey on the Flightweb listserve
and surveyed five of the largest air medical operators--as well as
information listed in the AAMS membership directory and the Directory
of Air Medical Programs, published in AirMed--to determine the number
of programs and helicopters.[Footnote 15] To determine the number of
flight hours, the authors multiplied the average flight hours per
program by the total number of programs identified in each year. As a
result, the AMPA study estimated that the total number of air medical
flight hours grew from 187,216 in 1998 to 217,584 in 2001, an increase
of 16 percent. FAA estimates were considerably higher for this period.
For example, for 2001, FAA estimated a total of 1 million air medical
flight hours.
Some other operations-related indicators are available, and they point
to an increase in activity. The 2002 AMPA study also estimated that the
total number of patients flown in air ambulances rose from 174,501 in
1998 to 203,772 in 2001, an increase of 17 percent. The study's authors
obtained these estimates by multiplying the number of air medical
programs by the average number of patients transported each year. Data
maintained by the Department of Health and Human Services' Centers for
Medicare and Medicaid Services indicate that the number of air
ambulance trips reimbursed by Medicare increased 24 percent, from 1.65
transports per 1,000 beneficiaries in 2001 to 2.04 transports per 1,000
beneficiaries in 2004. Finally, two recent studies by government
agencies, including the Congressional Research Service and FAA,
acknowledged the industry's growth.[Footnote 16] However, these
studies, like our own, did not find a fully comprehensive indicator of
this growth.
One other potential indicator of growth is the number of air ambulance
operators, but we were unable to find data showing the change in
operators over a several-year period. FAA maintains information about
the air ambulance operators it oversees, but only on those currently in
operation. As such, there was no way to determine how the number of
operators had changed over time. FAA data indicate that as of July 31,
2006, there were a total of 76 air ambulance operators. The number of
operators is considerably lower than the number of aircraft and bases.
This is because some operators have large fleets of aircraft and
operate from many bases. For example, Air Methods, the largest air
medical operator, operates 208 helicopters out of 96 bases. Government
and industry officials and operators we spoke with indicated that
industry consolidation was the current trend.
Growth Is Primarily in Stand-Alone Businesses and Has Led to Increased
Competition in Some Locales:
We did not find any data on the distribution of business models within
the air ambulance industry, but the consensus that emerged from the
industry officials we spoke with and the information we reviewed was
that growth has occurred mainly in the stand-alone (independent)
provider business model. For example, a 2006 public policy paper by the
Foundation for Air Medical Research & Education (FARE)[Footnote 17]
observed that many air medical services "had become independent,
community based resources." Similarly, an FAA research paper published
in September 2005 noted that "the fastest growing segment of the [air
medical] industry is the independent provider." In our interviews with
government and industry officials, there was general agreement that the
independent provider model has grown more than the traditional hospital-
based model.
Additional support for this view can be seen in the types of operating
bases that are growing most rapidly--airport and helipad bases, which
are the typical bases of stand-alone operators. According to the Atlas
and Database of Air Medical Services, the total number of stand-alone
bases increased more than hospital bases from 2003 to 2005 (see fig.
5). In 2003, the number of bases reported by AAMS members was about
equally divided between hospital bases and airport and helipad bases.
By 2005, the number of hospital bases had increased by 6 percent (from
234 to 249), while the number of airport and helipad bases had
increased by 53 percent (from 238 to 365).
Figure 5: Number of Hospital-Based and Airport and Helipad Air
Ambulance Bases, 2003 to 2005:
[See PDF for Image]
Source: Association of Air Medical Services, Atlas and Database of Air
Medical Services.
[End of figure]
The growth in the stand-alone business model has been influenced by the
potential for profit making, according to the officials we interviewed
and others who have studied the industry. The influencing factor they
most often cited was the 1997 mandate for the development of a Medicare
fee schedule for ambulance transports.[Footnote 18] Officials we spoke
with and literature we reviewed cited the implementation of the fee
schedule as a factor in the increase in stand-alone services. The fee
schedule was implemented gradually starting in 2002, and since January
2006, 100 percent of payments for air ambulance services have been made
under the fee schedule. Prior to 2002, all ambulance service
reimbursements by Medicare were based on the type of provider. Hospital-
based providers were reimbursed based on their reasonable costs, while
independent providers were reimbursed based on reasonable charges.
These payment patterns resulted in wide variation in payment rates for
the same service. In its final rule on the fee schedule published in
the Federal Register on February 27, 2002, the Centers for Medicare and
Medicaid Services anticipated that the fee schedule would redistribute
income from ground to air ambulance services and from hospital-based to
independent operators.
This potential for higher and more certain revenues has, in the opinion
of many of our sources, increased competition in certain areas. The
Phoenix and Dallas/Fort Worth areas were cited as examples of locales
where the presence of a large number of air ambulance operators
intensifies competition. One industry official wrote that there were
more air medical helicopters in Phoenix than in all of Canada.[Footnote
19] Another noted that the Dallas/Fort Worth area had been home to only
one operator for many years, but by mid-2006 it had eight air ambulance
operators.
Increased competition, according to industry experts, can also bring
potentially unsafe practices. Although we were unable to determine how
widespread these activities are, experts cited the potential for such
practices, including the following:
* Helicopter shopping: FAA defines this as the practice of calling, in
sequence, various operators until an operator agrees to take a flight
assignment, without sharing with subsequent operators the reasons the
flight was declined by previously called operators. This practice can
lead to an unsafe condition in which an operator initiates a flight
that it may have declined if it had been aware of all of the facts
surrounding the assignment.[Footnote 20] For example, in July 2004, a
medical helicopter collided with trees shortly after takeoff, killing
the pilot, flight nurse, flight paramedic, and patient. Three other air
ambulance operators had previously turned down this same flight,
including one who had attempted it but was forced to return due to fog.
The pilot during the accident, however, was not informed by emergency
medical service dispatchers that other pilots had declined the flight
due to the weather conditions. According to NTSB, inadequate dispatch
information contributed to the accident.
* Call jumping: Industry officials reported that call jumping occurs
when an air ambulance operator responds to a scene to which that
operator was not dispatched or when multiple operators are summoned to
an accident scene. This situation is potentially dangerous because the
aircraft are all operating in the same uncontrolled airspace--often
during nighttime or in marginal weather conditions--increasing the risk
of a midair collision or other accident. The term "call jumping"
originated in the 1970s when some ground ambulance services were
involved in a similar practice.
* Inappropriate use of air medical aircraft: One industry official has
posited that air medical helicopter use may be excessive, unsafe, and
not beneficial for most patients, citing recent studies that conclude
few air transport patients benefited significantly over patients
transported by ground and the recent increase in the number of air
medical accidents. Other studies have disagreed with this position,
citing air ambulances' impact on reductions in mortality by quickly
transporting critically injured patients.
Increase in Number of Accidents Has Led to Greater Industry Focus on
Safety-Related Activities:
From 1998 through 2005, the air ambulance industry averaged 11
accidents per year, according to NTSB data.[Footnote 21] The annual
number of air ambulance accidents increased from 6 in 1998 to a high of
18 in 2003, then receded to 12 in 2004 and 11 in 2005 (see fig. 6). Of
the 89 total accidents from 1998 to 2005, 31 accidents resulted in the
deaths of 75 people.[Footnote 22] Another nine accidents resulted in
serious injuries to passengers or crew. In 2003, the peak year for
accidents in our review period, there were 4 accidents with fatalities
and 1 with serious injuries. The remaining 2003 accidents had either
minor injuries (4) or no injuries (9).
Figure 6: Total Air Ambulance Accidents, 1998 to 2005:
[See PDF for Image]
Source: GAO analysis of NTSB data.
[End of figure]
The drop in the number of accidents in 2004 and 2005 came as the
industry undertook a series of steps designed to increase safety
awareness, discussed in further detail below. While this drop is a
favorable development relative to the number of accidents in 2003, the
numbers of accidents in 2004 and 2005 still closely match the overall
average for the period. In addition, the annual average of 11 accidents
for the 8-year period is higher than in previous years. Given the
apparent growth in the industry, an increase in the number of accidents
may not indicate that the industry has, on the whole, a poorer safety
record during our review period than in previous years. More
specifically, without actual data on the number of hours flown (data
that FAA does not gather at present but attempts to estimate), no
accident rate can be accurately calculated, eliminating the possibility
of determining whether the industry is becoming safer or more
dangerous.
The air ambulance industry's response to the higher number of accidents
has taken a variety of forms. These initiatives include efforts aimed
at flight-hour data collection, research into accident causes,
training, and sharing of recommended practices. For example, in 2005,
the Pilot Study Safety Group--with the support of FARE--sponsored a Web-
based survey of air medical pilots in which pilots were asked about
their primary safety concerns and what equipment they need to fly more
safely. As a result of the survey, the study group is recommending (1)
that a gold standard for air medical operators be established that
would include annual crew resource management[Footnote 23] training for
all personnel, (2) flight simulation training for all pilots that
includes motion and instrument meteorological conditions, and (3) night
vision aid or mission-oriented unaided night flight training for all
crew members. Table 2 highlights some of the other industry initiatives
we have identified. Although the impact of these initiatives on
reducing accidents has not been assessed, the decrease in the annual
number of industry accidents since 2003 may be an indicator that the
initiatives are having some effect. This seemed to be the case in the
mid-1980s when a reversal of the increasing accident trend occurred
after a combination of industry and FAA efforts.
Table 2: Examples of Air Ambulance Industry Initiatives to Address
Safety Concerns:
Year: 1999;
Organization: AAMS;
Initiative: Distributed a safety poster to its members and held "Safety
Day" at the Air Medical Transport Conference to focus on program
safety.
Year: 2000;
Organization: Air Medical Safety Advisory Council (AMSAC);
Initiative: Develops recommended practices for the industry.
Year: 2001/2002;
Organization: AMSAC;
Initiative: Implemented "Train the Trainer" Air Medical Resource
Management programs.
Year: 2002;
Organization: Air Medical Physicians Association;
Initiative: Published "A Safety Review and Risk Assessment in Air
Medical Transport.".
Year: 2005;
Organization: AAMS;
Initiative: Adopted "Vision Zero," the air medical community's program
to promote safety awareness.
Year: 2006;
Organization: AAMS;
Initiative: Sponsors the Flight Operational Database for Air Medical
Services--an effort to collect flight and flight-hour data for air
medical operators.
Year: 2006;
Organization: Air & Surface Transport Nurses Association;
Initiative: Published a position paper on transport nurse safety in the
transport environment.
Source: GAO.
[End of table]
FAA Safety Oversight Does Not Fully Address Industry's Operational
Risks:
FAA resources, safety inspections, and regulations are tailored to
oversee a wide range of aviation activities and do not address many of
the operational risks facing air ambulance operators; therefore, FAA
faces challenges in providing safety oversight of the air ambulance
industry. Compared with other operators, air ambulance transports are
subject to greater risks, because these flights often occur during
nighttime, in adverse weather, and to remote sites in order to provide
medical attention. Operational control often occurs away from
headquarters, and many individuals and systems are involved in
coordinating these flights, underscoring the role of human judgment and
risk-management protocols. Available data demonstrate the risks
inherent to the flight environment and stemming from poor judgment. For
example, NTSB data show that more than one-third of all fatal air
ambulance helicopter accidents involved weather. FAA inspections and
resources are not tailored to the air ambulance industry, as few
inspectors have the necessary qualifications to certify operators' use
of available safety technology, and inspections of satellite bases by
the assigned inspectors are infrequent. In addition, the requirements
within Part 135 regulations are broad and may not fully address the
dangers of poor decision making and the propensity for flights to occur
at night or to remote sites.
Air Ambulance Operations Face Risks Different from Those Faced by Other
Operations Subject to Part 135 Regulations:
Under Part 135 rules, FAA regulates a wide variety of aviation
operations, including both "scheduled" (commuter flights with fewer
than 10 seats) and "nonscheduled" (on-demand air carriers, including
air ambulances).[Footnote 24] Part 135 operations can include such
flights as small package cargo transport, business and personal
domestic and international transport, and shuttle services to
industrial job locations, such as oil platforms at sea. While these
operators may provide services in a variety of conditions, their
operations are generally characterized by smaller geographic operating
areas and more uniformity across their bases compared with that of air
ambulance operators. For example, these operators generally do not have
many remote bases and they take off and land at established landing
zones.
Operationally, air ambulance operations are distinct from these other
types of operations in several key ways:
* Operations are subject to greater risks. Air ambulance helicopters
are used to quickly transport individuals requiring urgent or emergency
medical attention at all hours of the day, and crews face greater risks
from flying at night, in marginal weather conditions, and to and from
remote sites. In "scene work" (picking up a sick or injured patient at
an off-airport/heliport site), the landing zone is a makeshift site to
which the pilot has likely never been. Such operations, coupled with
low visibility, can contribute to severe outcomes. Available data tend
to confirm that the air ambulance transports face greater risks than
other types of helicopter transports. NTSB data of helicopter accidents
occurring between 1998 and 2005 show that factors related to flight
environment (such as light, weather, and terrain) underlie 70 percent
of all air ambulance accidents, compared with 40 percent of accidents
for other helicopter accidents.[Footnote 25] Data on the flight
environment of air ambulance accidents indicate a number of risks,
including the following:
* Nighttime operations. Nighttime accidents for air ambulance
helicopters were more prevalent than for other helicopter operations,
and air ambulance accidents tended to be more severe when they occurred
at night than during the day. More than half of all air ambulance
helicopter accidents took place at night, compared with 9 percent of
non-air-ambulance helicopter accidents. Nighttime accidents also carry
a greater tendency to be fatal. NTSB data indicate that from 1998 to
2005, air ambulance accidents that occurred at night were almost four
times more likely to result in fatalities than those occurring during
the day--51 percent versus 13 percent (see fig. 7).
Figure 7: Time of Day of Air Ambulance Fatal and Nonfatal Accidents,
1998 to 2005:
[See PDF for Image]
Source: GAO analysis of NTSB data.
[End of figure]
* Adverse weather. Air ambulance accidents were more often associated
with weather conditions compared with other helicopter accidents.
Weather conditions such as snow, gusting wind, and fog have been known
to contribute to air ambulance accidents. While 4 percent of other
helicopter accidents are associated with bad weather, air ambulance
accidents were nearly four times more likely (15 percent) to be
attributed to adverse weather (see fig. 8). NTSB data show that
overall, more than one-third of fatal air ambulance accidents were
attributable in part to weather.
Figure 8: Percentage of Air Ambulance and Other Helicopter Accidents
Associated with Adverse Weather, 1998 to 2005:
[See PDF for Image]
Source: GAO analysis of NTSB data.
[End of figure]
* Remote sites. Flying to remote sites may further expose the crew to
other risks associated with unfamiliar topography or ad-hoc landing
sites. Data show that accidents attributable to an in-flight collision
with objects occurred more frequently for air ambulances than other
helicopters. Air ambulance helicopters also can encounter difficulties
with ad-hoc landing zones at remote sites, such as being engulfed in
clouds of dust commonly referred to as brownouts. For example, in July
1998 during a brownout, an air ambulance helicopter rolled over when
the pilot lost visual contact with the ground.
* Multiple bases located away from headquarters. FAA inspectors
assigned to large air ambulance certificates told us that the
dispersion of bases away from operator headquarters may result in less
disciplined adherence to internally established risk assessment
practices and protocols. Air ambulance bases are often dispersed away
from headquarters, either as independent stand-alone bases or through
contractual relationships with hospitals. In contrast, other Part 135
helicopter operations typically are not dispersed. The dispersion of
bases away from the certificate holders' headquarters and the location
of bases are in part due to medical need and demand for services. For
example, one state emergency medical services official reported that
operators look at high accident road intersections in considering where
to locate their bases.
* Many individuals and systems are involved in transports. Many
individuals and systems may be involved in coordinating air ambulance
transports. The number and expertise of people involved in making
decisions and passing on information about flights and flight
conditions can increase the risk of incorrect or incomplete information
being relayed. Multiple systems, involving both public and private
resources, are used in determining when to relay a request, which air
ambulance provider the request will be relayed to, and if a request
will be accepted and completed. Emergency medical service dispatchers
may not uniformly gather all of the information needed by air ambulance
providers, such as weather at the landing site. Ground personnel may
also be involved with relaying critical information about the landing
site to the crew; but again, they may not provide critical information
to the air ambulance operator. For example, in Parumph, Nevada, an air
ambulance helicopter crashed while attempting to pick up a patient at a
remote site when ground personnel incorrectly informed the helicopter
crew that there were no wires obstructing the site.
* Human judgment may override risk-based protocols. Human judgment can
play a critical role in air ambulance transport, particularly given the
risks found in the flight environment and the medical urgency. For
example, during a dark night in June 1998 in La Gloria, Texas, a
helicopter crashed into trees nearly 20 miles past the accident site to
which it was headed. Attributes of the crash, as reported by NTSB,
indicated that the pilot failed to recognize his intended destination
and had flown past it and that the adverse weather conditions resulted
in the pilot's loss of control from experiencing spatial
disorientation. The pressure to complete the airlift and the pilot's
lack of experience with flying by instruments were cited among the
contributing factors by NTSB in its accident report. The following
accident data highlight the prominence of poor human judgment in an
already inherently risky line of work:
- Ninety-four percent of air ambulance accidents between 1998 and 2005
had at least one cause related to pilot/operational errors, while 86
percent of non-air-ambulance accidents during the same time period had
pilot/operational causes.
- In total, 28 percent of air ambulance accidents between 1998 and 2005
had at least one planning or decision-making related cause, while 19
percent of non-air-ambulance accidents had such causes.
Air operators rely on a number of protocols, such as operational
control (the authority over initiating, conducting, and terminating a
flight), risk assessment matrices, and air medical resource management
training to help reduce the potential for poor or erroneous
judgment.[Footnote 26] However, there are indications that in air
ambulance operations, these protocols may be inconsistently implemented
or followed. According to an FAA report that reviewed air ambulance
accidents occurring from 1998 to 2004, a lack of operational control
and poor aeronautical decision making were significant contributing
factors to these accidents.[Footnote 27] Specifically, the report cited
the susceptibility of crew members to external factors in decision
making. FAA inspectors we spoke with reported that factors such as
competition and the contractual relationship between a vendor and
provider can result in a loss of operational control when unauthorized
medical or other staff exert pressure over the crew to fly. Several
trade organizations also said that the trend toward stand-alone
providers has increased the susceptibility of operational decision
making to financial incentives. Additionally, FAA inspectors we
interviewed reported that the dispersion of bases away from certificate
holder headquarters may result in less disciplined adherence to
internally established risk assessment practices and protocols.
FAA Inspections Framework Is Not Tailored to Risks of the Air Ambulance
Industry:
FAA faces challenges in providing safety oversight to the air ambulance
industry because the existing inspections approach and resources are
not tailored to address the specific operational aspects of air
ambulance transports. Current FAA inspections and resources may not
enable its staff to meet the workload, training, and travel
requirements associated with conducting oversight activities of air
ambulance certificates. These challenges stem from the distinctive way
that air ambulance operators are structured, their size, use of
emerging technology, and dispersed bases. In addition, FAA does not
collect data that would help demonstrate how its inspections approach
is connected to safety outcomes. These challenges are discussed in more
detail below.
* Size and scope of air ambulance operations. Each year, the National
Flight Standards Work Program Guidelines sets the minimum number of FAA
required inspections for all Part 135 operators. Although the National
Flight Standards Work Program Guidelines outlines the minimum
inspection requirements for all Part 135 operators, the principal
inspectors must determine how many additional inspections might be
necessary for adequate oversight in light of the size and risk factors
associated with a certificate holder. In the case of large air
ambulance operators, these additional inspections can be considerable
due to the size and scope of the operations. For example, according to
FAA officials, the certificate management team for one large air
ambulance operator had 2,396 hours of required inspector surveillance
hours for fiscal year 2006. However, the team estimates that a total of
4,425 inspector surveillance hours will actually be needed for fiscal
year 2006 in order to provide appropriate oversight. Additionally,
FAA's procedures for establishing and maintaining pay grades for
inspectors may be a contributing factor in how much attention is given
to the oversight of large air ambulance operators. FAA assigns points
to the inspection activities of inspectors, and these points, in turn,
are tied to an inspector's pay. Several inspectors of air ambulance
operators reported that the points assigned to the oversight of these
operators are not commensurate with the risk and size of these
operations.
* Lack of training and qualifications to oversee use of technology.
According to FAA inspectors and officials we spoke with, FAA has few
inspectors who have the necessary qualifications to certify the use of
safety technology being adopted by air ambulance operators, and FAA
does not provide inspectors with training in emerging safety
technology. Several of the FAA inspectors we interviewed reported not
receiving what they felt to be the necessary training that would allow
them to provide oversight of operators' implementation of new
technology. This is similar to concerns we raised in a previous report
on FAA's inspection program.[Footnote 28] Specifically, we found that
FAA develops technical courses on an ad-hoc basis rather than part of
an overall curriculum for each inspector specialty--such as air
ambulance operations--because the agency has not systematically
identified the technical skills and competencies each type of inspector
needs to effectively perform inspections. FAA developed the Flight
Standards Inspector Resource Program, in which inspectors with special
expertise in a technology can assist other inspectors whose operator
may be using such technology. For example, currently few inspectors are
qualified to provide operator certification in night vision goggle use.
However, several inspectors we spoke to found this program problematic,
because of the burden it poses to the inspector that must certify the
use of night vision goggles and continue to carry out their other
required duties.
* Limited oversight of base locations. While air ambulance bases and
helicopters for any one operator are often located across the country,
the assigned principal inspectors are based in the FAA district office
where the operating certificate is registered and held by an operator's
headquarters office. This may be important because operators may have
many remote bases of operations; for example, one of the largest air
ambulance companies has no helicopters located at the headquarters
location. FAA principal inspectors assigned to large air ambulance
certificates we spoke with said they did not have the travel funds or
time to perform inspections of many remote bases. Instead, inspectors
from local FAA offices--called geographic inspectors--assist with the
oversight of these bases at the request of a principal
inspector.[Footnote 29] Some FAA principal inspectors expressed little
confidence in the quality of these inspections, however, because
geographic inspectors may lack comprehensive knowledge of the
operators' manuals or lack helicopter expertise.
The challenges that FAA faces in applying its general inspections
approach to the air ambulance industry are also evident in its
violations and enforcement activities. Principal inspectors we spoke
with noted that the problems they typically found with air ambulance
operator certificates were generally tied to the maintenance of proper
paperwork and other record keeping irregularities, and not to known
industry safety issues such as risk management and decision making.
This may indicate that the factors that frequently contribute to air
ambulance accidents, such as flying at night or in adverse weather, are
not necessarily addressed by typical FAA oversight activities, which
focus on such things as maintenance and training. Additionally, FAA was
unable to provide us with reliable data of FAA enforcement actions
related specifically to helicopter air ambulances because enforcement
data for operators do not distinguish the actions taken against
operators' air medical operations from operators' other lines of
business. For example, the core business of Petroleum Helicopters
International (PHI), one of the largest air ambulance operators,
consists of providing offshore helicopter support to oil and gas
companies operating in the Gulf of Mexico. FAA enforcement data we
reviewed for PHI do not specify which enforcement actions were taken
against the company's air medical operations and its offshore
operations. Moreover, FAA only maintains data on enforcement actions
taken against air ambulance operators currently in operation. These
data limitations constrain FAA's ability to assess its air ambulance
oversight activities and are similar to the concerns we have previously
reported about FAA's inadequate evaluative processes with its
inspections and enforcement program.[Footnote 30]
Part 135 Regulations Do Not Address Specific Dangers Inherent in Air
Ambulance Transports:
Many air ambulance flights are subject to different weather and crew-
rest requirements under federal aviation regulations, depending on
whether patients or passengers are on board. For example, flights
without patients or passengers, such as flights en route to an accident
scene or as part of training exercises, are subject to minimum
requirements outlined in Part 91 regulations. When patients are on
board, Part 135 requirements are applicable. Some operators we
interviewed and visited reported that it is their company policy to
follow Part 135 requirements at all times and believed that the more
stringent requirements of Part 135 regulations offer safer operating
parameters.[Footnote 31]
Despite its more stringent requirements, Part 135 regulations cover a
broad range of operators and do not address the risks inherent in the
operational aspects of air ambulance transports--adding to FAA's
challenges in providing oversight of the air ambulance industry. For
example, Part 135 regulations do not distinguish the operational
control responsibilities of the certificate holder from the base or
hospital program, which may be important in this industry because many
air ambulance operations are geographically dispersed or involve third
parties, such as an emergency medical system communications specialist
or medical director. In a recent review of Part 135 operators, FAA
identified a problem of questionable operational control being
exercised by certificate holders working under commercial arrangements
with aircraft owners or management companies. In December 2006, FAA
issued Notice 8000.347, which reiterates existing regulation about the
exercise of operational control. The notice outlines that operational
control requires Part 135 operators to "put procedures in place to
ensure that when safety conditions for a flight cannot be met, the
flight is canceled, delayed, rerouted, or diverted." Because multiple
people are involved in dispatching air ambulance helicopters,
operational control, as outlined within the current Part 135
regulations, has been interpreted differently. According to one FAA
official, in some instances, tracking a flight or "flight following"--
one function of operational control--was being performed by the
hospital rather than the certificate holder because the former entities
were in two-way communication with the helicopter. The official noted
that this lack of formalized flight following inhibits the efficacy of
the certificate holder in maintaining control of the aircraft and
responsibility for the flight at all times.
Part 135 regulations are also not tailored to the air ambulance
industry's scene response transports that often require flights to
remote sites. Remote-site flights may require crews to use new or
different flight routes that can be further complicated by marginal
weather or flying at night. Within Part 135 regulations, instrument
flight rules allow for the use of instruments in guiding the aircraft
in inclement weather. However, in order to utilize instrument flight
rules equipment, weather reporting must be available for the
destination location. According to Part 135 regulations, if such
weather reporting is unavailable flights must use visual flight rules
(not instrument). According to some operators, since many air ambulance
flights are to remote landing sites or to hospitals that do not have
such weather reporting available, air ambulances can be inhibited in
their use of instrument flight rules equipment under Part 135.
[Footnote 32] Some industry trade organizations consider flights that
utilize instruments to be much safer than the flights that rely solely
on visual cues.
FAA Efforts to Improve Safety Are Under Way, but Effects Are Not Being
Measured:
While FAA has various efforts under way to address safety oversight of
the air ambulance industry, the agency currently is not assessing the
effects of these efforts. FAA's efforts have taken three main forms.
First, FAA has issued numerous items of guidance for its inspectors and
for air ambulance operators. The guidance directed at air ambulance
operators is not subject to enforcement because it is not mandatory,
and FAA has not established a way to track the extent to which
operators are voluntarily implementing these practices. Second, FAA has
authorized additional inspectors to oversee large air ambulance
operators and taken other steps designed to improve the safety of large
operations. Third, FAA has increased collaboration with air ambulance
industry officials through sponsorship of and attendance at meetings
and conferences that address industry safety issues. However, FAA has
no way to measure the impacts of these safety efforts because FAA does
not collect basic data about industry trends, such as flight hours,
that are necessary to indicate if accident rates are increasing or
decreasing. Additionally, the extent to which operators are following
FAA voluntary guidance is not currently tracked. Without an approach
for evaluating the effects of FAA efforts, it will be difficult to
determine whether the current approach and level of FAA safety
oversight of the air ambulance industry is appropriate.
FAA Efforts Targeted at Improving Air Ambulance Safety Oversight
Include Issuing Guidance, Expanding Inspection Resources, and
Collaborating with the Industry:
FAA has taken a number of steps to develop initiatives and strategies
to reduce the number of air ambulance accidents. In August 2004, FAA
established the FAA Emergency Medical Services Task Force to review and
guide government and industry efforts to reduce air ambulance
accidents. The FAA task force initiated a collaborative relationship
with air ambulance industry officials that resulted in FAA developing
and publishing numerous pieces of aviation safety guidance, including
FAA notices aimed at improving the safety of air ambulances.
Additionally, FAA has recently authorized an increase in the size of
the inspection teams overseeing large air ambulance operators. Beyond
the 2004 task force, FAA has worked together with the industry in a
number of ways to help address the safety of air ambulances.
FAA Guidance Focuses on Identified Safety Concerns:
FAA has issued guidance for air ambulance inspectors and operators that
focus on a number of safety issues identified by the FAA task force's
review of air ambulance accidents (see table 3). FAA's recently
published guidance has been largely targeted at FAA safety inspectors
of air ambulance operators, but it also recommends actions for
operators to take to improve safety. All published notices containing
the guidance expire 1 year after their effective date. Key areas of
emphasis for inspectors to relay to operators include improving
decision-making skills, risk management, and operational control.
Table 3: Key FAA Published Efforts to Improve Air Ambulance Safety:
Date: January 2005;
Type of action: Notice 8000.293 (on Jan. 28, 2006, became permanent
through Safety Alert for Operators 06001);
Title: Helicopter Emergency Medical Service Operations;
Purpose: Provides guidance for FAA safety inspectors to help operators
review pilot and mechanic decision-making skills, procedural adherence,
and crew resource management practices.
Date: August 2005;
Type of action: Notice 8000.301;
Title: Operational Risk Assessment Programs for Helicopter Emergency
Medical Services;
Purpose: Provides guidance to FAA inspectors to promote improved risk
assessment programs and risk management tools and training to all
flight crews, including medical staff.
Date: September 2005;
Type of action: Notice 8000.307;
Title: Special Emphasis Inspection Program for Helicopter Emergency
Medical Services;
Purpose: Provides guidance to FAA safety inspectors of air ambulance
operators to place emphasis on specific areas, including operational
control (policies, procedures, training, etc), safety culture
development, access to weather information, operators' knowledge of
geographic area, etc.
Date: September 2005;
Type of action: Advisory Circular 00-64;
Title: Air Medical Resource Management;
Purpose: Provides guidance to operators to establish minimum training
guidelines for all air medical team members.
Date: January 2006;
Type of action: Flight Standards Handbook Bulletin for Air
Transportation, 06-02;
Title: Helicopter Emergency Medical Services Loss of Control and
Controlled Flight into Terrain Accident Avoidance Programs;
Purpose: Provides information to inspectors about pilot training and
checking standards and requires a review of air ambulance operator
training programs.
Date: January 2006;
Type of action: Flight Standards Handbook Bulletin for Air
Transportation, 06-01;
Title: Helicopter Emergency Medical Services; OpSpec A021/A002
Revisions;
Purpose: Provides guidance to principal operations inspectors about
revisions to the weather minimums for air ambulance operators.
Date: March 2006;
Type of action: Notice 8000.318;
Title: Public Helicopter Emergency Medical Services Operations;
Purpose: Provides guidance to inspectors to ensure that public air
ambulance operators are aware of current FAA policies and standards for
air ambulance operations, and to emphasize the importance of public
aircraft operators' compliance with these operating rules.
Date: August 2006;
Type of action: Aeronautical Information Manual;
Title: Helicopter Night Visual Flight Rule Operations;
Purpose: Provides information and guidance concerning night celestial
and man- made lighting on seeing conditions in night visual flight rule
operations.
Date: August 2006;
Type of action: Aeronautical Information Manual;
Title: Landing Zone Information;
Purpose: Provides information and guidance on the selection of ad-hoc
helicopter landing sites by ground responders and the use of such sites
by helicopter operators.
Date: November 2006;
Type of action: Notice 8000.333;
Title: Helicopter Emergency Medical Services (HEMS) use of the Aviation
Digital Data Service (ADDS) Experimental HEMS Tool; Purpose: Provides
information and guidance to principal inspectors on the use of the
ceiling and visibility tool developed as a result of the 2006 Weather
Summit.
Source: FAA.
[End of table]
FAA notices require actions by FAA personnel but are nonmandatory to
the air ambulance operators and not subject to enforcement. For
example, in Notice 8000.301, which concerns risk assessment programs,
principal inspectors are to review the notice, provide a copy to their
assigned operators, and "strongly encourage" operators to implement a
risk assessment program. FAA inspectors told us that this published
guidance is difficult to enforce and agreed that although many of the
air ambulance operators are proactive in implementing FAA guidance,
there is no way to ensure that operators adopt the guidance. An
official from Professional Airways Systems Specialists, the union
representing FAA inspectors, also commented that principal inspectors
have no way to compel operators to adopt this guidance, because the
enforcement tools they have (e.g., approving the operators' general
operating manuals and levying sanctions and fines) are rooted in
established regulations, not in the "good ideas" of the voluntary
guidance. Additionally, FAA officials noted that in areas where there
has been some industry resistance, such as new equipment
recommendations, inspectors have little recourse. However, FAA
officials told us that rule making is a time-consuming process that can
take years to complete, hindering the agency's ability to quickly
respond to emerging issues. By issuing guidance rather than
regulations, FAA has been able to quickly respond to concerns about air
ambulance safety. Officials added that FAA has not ruled out future
regulatory action.
Industry officials and air ambulance operators we interviewed were
largely supportive of FAA's efforts to provide additional guidance on
air ambulance safety and reported that most operators are implementing
this guidance. For example, CAMTS has adopted much of FAA's guidance
within its accreditation standards for operators and, in cases such as
risk assessment, has adopted more stringent standards than FAA
encourages. Air ambulance operators also reported that they were
already operating at higher standards than FAA recommends in guidance,
such as weather minimums and safety equipment. Many industry groups and
operators do not believe that additional regulations would be more
effective than the published guidance. For example, the Helicopter
Association International, a professional trade association for the
civil helicopter industry, has stated that adherence to current
regulations is far more effective than generating new regulations and
has encouraged air ambulance operators to adopt FAA guidance to the
maximum extent possible to enhance safety.
Additional FAA Resources Allocated to Air Ambulance Oversight:
FAA recently authorized the hiring of new inspectors to work on the
certificate management teams for large air ambulance operators. In
2005, FAA sanctioned a group to review the resource needs for oversight
of air ambulance operators with 25 or more dedicated air ambulance
helicopters. Following this review, the task team made several
recommendations to FAA headquarters that included increasing the number
of FAA inspectors assigned to large air ambulance operators, dedicating
these inspectors solely to air ambulance operator certificates (i.e.,
no other inspection responsibilities), and using the surveillance and
evaluation program (SEP) to identify risks and target surveillance
activities.[Footnote 33] As a result of the task team recommendations,
in June 2006, FAA accepted these recommendations and authorized an
increase in the number of staff assigned to the inspection teams that
oversee the seven large air ambulance operators.[Footnote 34] For four
of the seven largest operators, the size of the inspection teams will
increase to eight inspectors to oversee the air ambulance operator
certificates.[Footnote 35] Additionally, the principal inspectors and
newly hired inspectors for these operators will be dedicated to the
certificate. Prior to this effort, many of the principal inspectors for
large air ambulance operators were responsible for more than 20
different certificates. Following this hiring, and implementation and
use of SEP, FAA will evaluate whether a further increase in inspection
team sizes is necessary. Hiring efforts by FAA to fill these inspector
positions are under way, and hiring is expected to be completed in
fiscal year 2007.
FAA also initiated a series of efforts to improve the safety of one
large air ambulance operator in 2005, and officials reported that they
hope some of the changes and recommendations being adopted by this
operator will be implemented industrywide. FAA concluded that the
recent increase in accidents of this operator emphasized the need for a
new approach to FAA's involvement in the effort to enhance safety for
air ambulance operators in general. The team working with the operator
has since recommended changes to FAA to improve oversight, including
increased and more focused surveillance, relieving inspectors of other
certificate duties, and adding appropriately qualified inspectors.
Additionally, the team has worked closely with the operator to evaluate
the company safety program, encourage risk management, and to change
some parameters for flights, including weather minimums.
FAA Has Increased Collaboration with the Industry:
In addition to collaborating with the air ambulance industry on
developing FAA guidance, FAA officials have worked together with the
industry in a number of other ways, such as attending and participating
in industry meetings, conferences, and task teams. For example, in
March 2006, FAA hosted a Weather Summit to identify the air ambulance
issues related to weather products and services and determine how FAA
can better meet industry needs. Additionally, FAA officials participate
in the AAMS Safety Committee and have made presentations at recent
industry conferences, such as the Helicopter Safety Forum and the Air
Medical Transport conference, to keep the industry informed of FAA
efforts related to air ambulance oversight.
FAA officials also reported that they are working with the industry to
address recent NTSB safety concerns but have not issued any new
regulations for air ambulance operators as NTSB recommended. In its
January 2006 Special Investigation Report on air ambulance operations
and accidents, NTSB made four recommendations to FAA to improve air
ambulance safety (see table 4). With these recommendations NTSB
encouraged FAA to impose requirements for air ambulance operators
because NTSB does not anticipate that the recently published FAA
guidance will be widely implemented by operators due to its voluntary
nature.[Footnote 36]
Table 4: NTSB Recommendations and FAA Responses:
NTSB recommendation to FAA: Require all air ambulance operators to
comply with Part 135 operations specifications during the conduct of
all flights with medical personnel on board;
FAA response: FAA is looking at options to address concerns about the
differences in the flight rules--specifically the weather minimums--
through new weather reporting requirements and the application of
"eligible on demand" standards to air ambulance helicopter operations.
NTSB recommendation to FAA: Require all air ambulance operators to
develop and implement flight risk evaluation programs;
FAA response: FAA has implemented this recommendation with the
publication of Notice 8000.301.
NTSB recommendation to FAA: Require air ambulance operators to use
formalized dispatch and flight-following procedures;
FAA response: FAA has a study under way to identify best industry
practices in ground communication and dispatch to support effective FAA
requirements and policy.
NTSB recommendation to FAA: Require air ambulance operators to install
terrain awareness and warning systems on their aircraft and to provide
adequate training to ensure that flight crews are capable of using the
systems;
FAA response: FAA has emphasized the strategic avoidance of controlled
flight into terrain accidents in Flight Standards Handbook Bulletin for
Air Transportation, 06-02. At FAA request, RTCA Inc., a private
corporation, has formed a special committee to develop the minimum
operational standards for helicopter terrain awareness and warning
systems, which will be used by FAA in developing future requirements.
Sources: NTSB and FAA.
[End of table]
Industry officials we spoke with generally agreed with the NTSB report
recommendations but did raise some concerns. Some industry officials
were concerned about the recommendation that air ambulances operate
under Part 135 at all times, noting that this could inhibit transports
in some areas due to a lack of weather information. For example, in a
response letter addressed to NTSB, CAMTS stated that while the balance
between lesser and more stringent regulation has always been a concern,
it is difficult to operate under Part 135 regulations in rural areas
due to airport and landing restrictions. Additionally, many industry
officials expressed concerns about the costs related to implementing
terrain awareness and warning systems, and some stated that this
technology may not be appropriate for helicopters due to the low
altitudes in which they operate. For example, AAMS has stated that the
NTSB has seriously underestimated the costs involved in implementing
terrain awareness and warning systems and has pointed out that, on one
aircraft, the cost of the computer portion of this technology (which
they say is the smallest part of the implementation costs) can range
from $14,000 to $30,000. AAMS supports voluntary implementation of
terrain awareness and warning systems due to the high costs involved in
implementing the systems and limited proven benefits, especially in
helicopter operations.
FAA Lacks an Approach for Evaluating the Effects of Its Efforts:
While the efforts by FAA could have had an effect on safety, the extent
of any effect is unknown because FAA does not collect necessary data to
evaluate effectiveness. FAA efforts such as increasing its inspector
workforce allow FAA to conduct more inspections and potentially improve
oversight of air ambulance operators. However, whether this increased
attention results in a better safety record will be difficult to
determine without the data to conduct an analysis of the industry
accident rate. FAA does not currently collect basic data to measure
changes in the air ambulance industry, such as flight hours or number
of trips flown. Without data about the number of flights or flight
hours, FAA and the air ambulance industry are unable to identify
whether the increased number of accidents has resulted in an increased
accident rate or whether it is a reflection of the growing number of
aircraft and programs. Data describing the safety trends of the
industry is essential to understanding the effects of FAA efforts,
especially as FAA continues to develop initiatives and dedicate
resources to improve air ambulance safety. NTSB has also stated the
need for valid activity data for Part 135 operators, not only to
compare accident rates, but also to establish baseline measures to be
used to identify and track accident trends and to assess the
effectiveness of safety improvement efforts.[Footnote 37]
Air ambulance flight hours and number of trips, while not currently
collected by FAA, appear readily available. According to current
regulations, Part 135 operators are not required to maintain flight-
hour activity data, but most FAA inspectors and air ambulance operators
we spoke with said that this information is available. Air ambulance
operators maintain records on the number of flights and flight hours
for a number of reasons, including to track the maintenance of the
helicopter equipment, to track the costs associated with flights (for
billing purposes), and to make business decisions such as where to
place additional aircraft or crew. Operators we spoke with did not
express concerns about reporting flight-hour or trip information to
FAA. FAA officials reported that principal inspectors can get this
information from operators, but regulatory changes would be necessary
to require operators to report it to FAA. To address the lack of
national data, the industry has an effort under way to create a
database of air ambulance flight operations information. This
initiative is still in the preliminary stages.
FAA also has no way to determine whether air ambulance operators are
implementing published guidance. Although FAA inspectors are required
to use FAA databases to record that guidance has been disseminated to
air ambulance operators, there is no mechanism to report whether
operators implemented the voluntary guidance. By issuing guidance for
operators to adopt, rather than making changes through regulations, FAA
has expedited the process of relaying safety information and
encouraging safety initiatives by operators. However, without a
mechanism to record whether operators are adopting this guidance, FAA
is unable to link these efforts to any specific results. For example,
according to Notice 8000.293, FAA inspectors were to encourage air
ambulance operators to consider using enhanced vision systems and
terrain awareness and warning systems for night operations. Without
information about which operators adopted this guidance, FAA will not
be able to link this effort to safer flights or fewer accidents and
will thus be unable to determine whether voluntary guidance is an
effective means to direct air ambulance operator safety efforts.
Conclusions:
The number of air ambulance accidents, while decreasing somewhat over
the last 2 years, remains above historic levels. FAA and the industry
have implemented numerous efforts to improve the safety of air
ambulances. However, FAA lacks basic information on the industry and
its safety efforts, including the number of flights and flight hours,
the number and location of air ambulance aircraft, and the number of
violations and enforcement actions against air ambulance operations.
This inhibits FAA's ability to gain a complete understanding of the
industry and whether its efforts are sufficient. FAA needs data about
the air ambulance fleet and operations, as well as the ability to track
and evaluate the implementation of its voluntary guidance to operators.
Without this information, FAA cannot assess the safety of the industry.
Further, this lack of information makes it difficult to determine the
extent to which operators are making changes and the effect the efforts
are having. Given the differences between air ambulance operators and
other Part 135 operators FAA oversees, as well as the challenges FAA
faces in responding to inherent safety concerns of the industry, a
clear understanding of trends and actions taken appears important in
deciding if the current regulatory approach is appropriate or if more
fundamental changes, such as revising FAA regulations or inspection
processes, need to be considered.
Recommendations for Executive Action:
To help FAA monitor industry growth trends, accident rates, and
operator implementation of FAA guidance, we recommend that the
Secretary of Transportation direct the Administrator of FAA to take the
following two actions:
* Identify the data necessary to better understand the air ambulance
industry and develop a systematic approach for gathering and using this
data. At a minimum, this data should include the number of flights and
flight hours, the number and locations of air ambulance helicopters,
and the number and types of FAA violations and enforcement actions
related to the air ambulance fleet.
* Collect information on the implementation of voluntary FAA guidance
by air ambulance operators and evaluate the effectiveness of that
guidance.
Agency Comments and Our Evaluation:
We provided a draft of this report to DOT for their review and comment.
On February 8, 2007, we met with DOT and FAA officials, including the
Deputy Director of FAA's Flight Standards Service, to obtain their oral
comments on the draft report. Overall, these officials agreed with the
report's findings and conclusions, and agreed to consider the
recommendations. FAA officials also provided technical comments, which
were incorporated in this report, as appropriate. We also provided a
draft of this report to NTSB for their review and comment. On January
30, 2007, NTSB's Audit Liaison provided technical comments, which were
incorporated, as appropriate, and confirmed that NTSB agreed with the
report's findings, conclusions, and recommendations via e-mail. In
addition, we provided a draft of this report to AAMS since AAMS is a
leading air ambulance industry representative. AAMS provided written
comments, which are reprinted in appendix III. AAMS also provided
technical comments, which were incorporated, as appropriate.
As agreed with your office, unless you publicly announce the contents
of this report earlier, we plan no further distribution until 14 days
from the report date. At that time, we will send copies to appropriate
congressional committees, the Secretary of Transportation, and the
Chairman of the National Transportation Safety Board. We will also make
copies available to others on request. In addition, the report is
available at no charge on the GAO Web site at [Hyperlink,
http://www.gao.gov].
If you have any questions about this report, please contact me at (202)
512-2834 or dillinghamg@gao.gov. Contact points for our Offices of
Congressional Relations and Public Affairs may be found on the last
page of this report. GAO staff who made major contributions to this
report are listed in appendix IV.
Sincerely yours,
Signed by:
Gerald L. Dillingham, Ph.D.
Director, Physical Infrastructure Issues:
[End of section]
Appendix I: Scope and Methodology:
To identify and describe the recent trends in the air ambulance
industry, we reviewed literature and analyzed data on industry
composition, size, and accidents. The literature we reviewed included
government, industry, and academic studies, reports, and other
documents regarding the evolution of the industry in terms of
composition, size, accidents, and safety initiatives. The Federal
Aviation Administration (FAA) data included estimates of flight hours
and aircraft based on its General Aviation and Air Taxi Activity and
Avionics survey for 1999 to 2004, data on numbers of inspectors and
operators (as of 2005), and numbers and types of violations and
enforcement actions from various FAA databases for 1998 to 2005. The
Association of Air Medical Services data, from the Atlas and Database
of Air Medical Services, included numbers of bases and dedicated
aircraft for 2003 to 2005. To examine the relationship between changes
in Medicare reimbursement rules and industry trends, we analyzed data
on Medicare reimbursed air ambulance trips from 1998 to 2005, as well
as trips by type of air ambulance provider for 2001 and 2004; these
data were obtained from the Medicare claims database. Based on reviews
of data documentation, interviews with relevant officials, and tests
for reasonableness, we determined that the data we used were
sufficiently reliable for the purposes of our study. We also
interviewed officials from the National Transportation Safety Board
(NTSB), academic experts, and industry and trade group representatives
about trends in the nature and scope of the industry and overall safety
concerns. Table 5 lists the industry and trade organizations we
contacted.
Table 5: Industry and Trade Organizations Interviewed:
Organizations:
Air Medical Physicians Association.
Air Medical Safety Advisory Council.
Air, Surface, and Transport Nurses Association.
Association of Air Medical Services.
Commission on Accreditation of Medical Transport Systems.
Helicopter Association International.
International Association of Flight Paramedics.
National Association of Air Communications Specialists.
National Association of State Emergency Medical Services Officials.
National Emergency Medical Services Pilots Association.
Professional Airways Systems Specialists.
R. Dixon Speas Associates.
Source: GAO.
[End of table]
To assess challenges to FAA oversight, we reviewed federal laws,
regulations, and guidance on air ambulance safety to better understand
the nature and extent of FAA's oversight role. Further, we interviewed
FAA Flight Standards officials in headquarters, inspectors, and
certificate management teams for air ambulance operators, as well as
industry officials and other experts, about air ambulance safety and
challenges to FAA oversight.
To help identify the key safety risks, we obtained and analyzed data
from NTSB's Aviation Accident Database on accidents that occurred from
January 1, 1998, to December 31, 2005. Our analysis of the NTSB data
formed the basis of the descriptive and comparative information on air
ambulance accidents shown throughout this report. According to NTSB, an
aviation accident is "an occurrence associated with the operation of an
aircraft which takes place between the time any person boards the
aircraft with the intention of flight and all such persons have
disembarked, and in which any person suffers death or serious injury,
or in which the aircraft receives substantial damage." Accidents were
included in our analysis as a helicopter air ambulance accident if the
database showed (1) the accident involved a helicopter being operated
by an air medical transport company and (2) the accident occurred
during flight under either Part 91 or Part 135 regulations. For this
period, we identified a total of 89 helicopter air ambulance accidents
that occurred under Part 91 or Part 135 flight rules and analyzed data
about these accidents to determine key contributing causes and
factors.[Footnote 38] All accidents involving public operators were
excluded from our analysis. We also conducted analyses comparing these
89 air ambulance accidents with other helicopter accidents during the
same time period.
To assess the reliability of the NTSB data, we (1) performed electronic
testing for accuracy, completeness, and consistency; (2) reviewed
internal NTSB documents about its collection, entry, and maintenance;
and (3) interviewed officials in NTSB's Office of Aviation Safety and
Office of Research and Engineering who were knowledgeable about the
content and limitations of these data. We determined that these data
were sufficiently reliable for the nationwide descriptive and
comparative analyses used in this report. We documented the procedures
that we used in our analyses and submitted them to officials in NTSB's
Office of Research and Engineering for their review and concurrence.
To learn more about air ambulance safety risks and concerns, we
conducted a total of five site visits of air ambulance providers in
Arizona, California, Maryland, Texas, and Washington. We chose these
states based on the presence of a large air ambulance market,[Footnote
39] state accreditation requirements, or an operating public provider.
To have access to a greater number of providers representing a variety
of business models, operational characteristics, and accident
histories, we narrowed our possible site visit locations to large air
ambulance markets. To examine the relevance and describe the extent of
state accreditation requirements, we included states with and without
these requirements. Lastly, to learn about the policies and practices
public providers may be engaged in that impact safety, we chose states
that had a public operator.
We selected the providers based on a number of operational
characteristics to include a variety of business models (hospital-based
and stand-alone programs, and public and private programs) and
certificate holder arrangements (operating certificate held by program
or vendor). During these site visits, we interviewed company officials,
including pilots, and obtained documentation of some programs' flight
safety protocols. Table 6 provides a description of each state we
visited.
Table 6: Description of States Selected for Site Visits:
State: Arizona;
Description of air ambulance market:
Providers: 10;
Helicopters: 50;
Accidents, 1998 to 2005: 8;
State requirements: The state requires licensing for all air ambulance
providers through the Arizona Department of Health Services. Inspection
and registration for all air ambulance units operating in Arizona is
required on a yearly basis. If a provider is accredited by the
Commission on Accreditation of Medical Transport Systems (CAMTS), the
state requirement for a licensure inspection is waived;
Description of programs visited:
* Native Air, a subsidiary of Omniflight Helicopters, is a community-
based operator, and its fleet is composed of 15 helicopters located at
12 bases in Arizona and Montana.
State: California;
Description of air ambulance market:
Providers: 28;
Helicopters: 72;
Accidents, 1998 to 2005: 7;
State requirements: The state of California has delegated authority to
local governments for emergency medical services (EMS). County
governments are responsible for coordinating emergency medical
services, including the coordination and monitoring of air ambulance
services;
Description of programs visited:
* The FlightCare Program at Enloe Medical Center is a nonprofit
hospital-based program. The program's fleet consists of one helicopter
based at the Enloe Hospital helipad;
* REACH is an independent for-profit air ambulance provider. The
company has seven helicopters and nine bases in California and Oregon;
* CALSTAR is a nonprofit community-based program. The company's fleet
consists of 11 helicopters and seven bases in California;
* The California Highway Patrol operates as an air rescue provider. The
California Highway Patrol maintains a fleet of 14 helicopters, 11 of
which are partially used for medical emergency transport and air
rescue. These helicopters are based at nine locations throughout the
state.
State: Maryland;
Description of air ambulance market:
Providers: 3;
Helicopters: 18;
Accidents, 1998 to 2005: 1;
State requirements: Maryland requires private providers of air
ambulance services operating in the state to be licensed by the state
and CAMTS accredited;
Description of programs visited:
* The Maryland State Police Aviation Command is a public provider and
has a fleet of 12 helicopters based in eight locations across the
state.
State: Texas;
Description of air ambulance market:
Providers: 23;
Helicopters: 61;
Accidents, 1998 to 2005: 13;
State requirements: The state requires air ambulances and providers to
be licensed by the Texas Department of State Health Services. The
licensure process requires providers to submit a copy of their current
FAA operational certification that includes designation for air
ambulance operations;
Description of programs visited:
* Teddy Bear Transport of Cook Children's Medical Center is a hospital-
based program that conducts hospital-to-hospital transports for
pediatric patients. The program contracts with a vendor for its
aviation services and operates one helicopter;
* PHI Air Medical is an independent program conducting a mix of scene
response and hospital-to-hospital transports. PHI's programs in Texas
include 12 helicopters stationed at 12 bases. In total, the company has
224 air ambulance helicopters stationed at 49 bases in 14 states.
State: Washington;
Description of air ambulance market:
Providers: 2;
Helicopters: 10;
Accidents, 1998 to 2005: 3;
State requirements: The state requires providers and air ambulances to
be licensed through the Washington Department of Health. Providers must
be accredited by CAMTS. Air ambulance licensure applicants must affirm
in the application that their service meets all FAA regulations, and
they must also provide a copy of their current FAA certificate and
operational specifications;
Description of programs visited:
* Airlift Northwest is a nonprofit community-based program. The program
contracts out its aviation services. Its fleet consists of six
helicopters stationed at four bases in Washington.
Source: GAO.
[End of table]
To supplement information gathered through interviews and visits with
local program officials, we also conducted semistructured interviews
with management officials from five of the largest air ambulance
operators to discuss air ambulance safety and trends. We also met with
local geographic and assigned principal FAA inspectors to learn more
about their roles and responsibilities in the oversight of the programs
we visited.
To describe the FAA efforts in addressing safety oversight challenges,
we identified and reviewed regulatory and voluntary guidance
implemented by FAA to address safety in the air ambulance industry. We
reviewed advisory circulars, notices, and other guidance issued by FAA
since 2004. We also obtained and reviewed documentation of FAA's
heightened oversight of one air ambulance operator and other documents
regarding staffing levels for the certificate management teams of large
air ambulance operators.
[End of section]
Appendix II: NTSB Air Ambulance Accident Data:
According to NTSB, from January 1998 through 2005, 89 air ambulance
accidents took place, resulting in 75 fatalities, 31 serious injuries,
and 27 minor injuries. An additional 133 people involved in these
accidents suffered no injuries. Of the 89 accidents, 64 took place
during Part 91 flight and the remaining 25 took place during Part 135
flight. Forty-seven of the accidents took place during the night and
the remaining 42 took place during the day. Table 7 provides
information collected from NTSB on each of these accidents.
Table 7: NTSB Air Ambulance Accident Information, 1998 through 2005:
Year: 1998;
Flight regulation: 135;
When accident occurred: Night;
Number of fatalities, injuries, or uninjured: 4 fatalities;
State: UT;
Accident details: An air ambulance helicopter transporting an injured
skier to a hospital was destroyed when it collided with mountainous
terrain after flying into known adverse weather.
Year: 1998;
Flight regulation: 91;
When accident occurred: Day;
Number of fatalities, injuries, or uninjured: 3 injuries;
State: AR;
Accident details: An air ambulance helicopter en route to pick up a
patient from a hospital was substantially damaged during a hard landing
following a loss of engine power.
Year: 1998;
Flight regulation: 91;
When accident occurred: Night;
Number of fatalities, injuries, or uninjured: 3 fatalities;
State: TX;
Accident details: An air ambulance helicopter en route to an accident
scene collided with terrain and trees after encountering poor
visibility conditions.
Year: 1998;
Flight regulation: 91;
When accident occurred: Night;
Number of fatalities, injuries, or uninjured: 3 uninjured;
State: CA;
Accident details: An air ambulance helicopter was destroyed when it
rolled over while attempting to land at a makeshift landing zone near
an accident site.
Year: 1998;
Flight regulation: 91;
When accident occurred: Night;
Number of fatalities, injuries, or uninjured: 3 fatalities;
State: IA;
Accident details: Due to faulty components, an air ambulance helicopter
experienced an in-flight breakup during descent and was destroyed.
Year: 1998;
Flight regulation: 135;
When accident occurred: Night;
Number of fatalities, injuries, or uninjured: 4 uninjured;
State: ID;
Accident details: An air ambulance helicopter taking off from an off-
site landing zone sustained substantial damage when it collided with
wires.
Year: 1999;
Flight regulation: 91;
When accident occurred: Night;
Number of fatalities, injuries, or uninjured: 3 injuries;
State: OH;
Accident details: An air ambulance helicopter en route to pick up a
patient from a hospital was destroyed when it impacted a house after
the pilot inadvertently entered snowy conditions.
Year: 1999;
Flight regulation: 135;
When accident occurred: Day;
Number of fatalities, injuries, or uninjured: 5 uninjured;
State: TX;
Accident details: An air ambulance helicopter transporting a patient to
a hospital from an accident scene was substantially damaged when it
impacted power lines during takeoff.
Year: 1999;
Flight regulation: 91;
When accident occurred: Night;
Number of fatalities, injuries, or uninjured: 3 fatalities;
State: NV;
Accident details: An air ambulance helicopter returning to base after
transporting a patient to a hospital was destroyed after encountering
deteriorating weather conditions and colliding with terrain.
Year: 1999;
Flight regulation: 91;
When accident occurred: Day;
Number of fatalities, injuries, or uninjured: 3 uninjured;
State: FL;
Accident details: An air ambulance helicopter en route to pick up a
patient collided with a building while hovering in preparation for
takeoff.
Year: 1999;
Flight regulation: 91;
When accident occurred: Day;
Number of fatalities, injuries, or uninjured: 1 uninjured;
State: MO;
Accident details: An air ambulance helicopter impacted terrain (during
takeoff from a helipad located on top of a hospital) because an
auxiliary power line was still attached to the helicopter.
Year: 1999;
Flight regulation: 91;
When accident occurred: Night;
Number of fatalities, injuries, or uninjured: 3 injuries;
State: FL;
Accident details: An air ambulance helicopter crashed when approaching
an off-site landing zone to pick up a patient.
Year: 1999;
Flight regulation: 135;
When accident occurred: Day;
Number of fatalities, injuries, or uninjured: 4 uninjured;
State: MT;
Accident details: An air ambulance helicopter collided with a tower
during takeoff from a remote site.
Year: 2000;
Flight regulation: 91;
When accident occurred: Night;
Number of fatalities, injuries, or uninjured: 3 uninjured;
State: TN;
Accident details: An air ambulance helicopter was substantially damaged
when it collided with a tree while attempting to land at a roadside
landing zone.
Year: 2000;
Flight regulation: 135;
When accident occurred: Night;
Number of fatalities, injuries, or uninjured: 4 fatalities;
State: TX;
Accident details: An air ambulance helicopter transporting a patient to
a hospital was destroyed when it impacted terrain after flying into
known adverse weather conditions.
Year: 2000;
Flight regulation: 91;
When accident occurred: Day;
Number of fatalities, injuries, or uninjured: 2 uninjured;
State: MN;
Accident details: An air ambulance helicopter returning from dropping
off a patient was substantially damaged from an in-flight collision
with a warehouse.
Year: 2000;
Flight regulation: 91;
When accident occurred: Day;
Number of fatalities, injuries, or uninjured: 3 fatalities;
State: FL;
Accident details: An air ambulance helicopter traveling back to base
after completing an interfacility transport collided with a radio
transmission tower and was destroyed.
Year: 2000;
Flight regulation: 91;
When accident occurred: Night;
Number of fatalities, injuries, or uninjured: 3 uninjured;
State: TX;
Accident details: An air ambulance helicopter was substantially damaged
when the tail rotor contacted trees while attempting to land at an
accident site.
Year: 2000;
Flight regulation: 91;
When accident occurred: Night;
Number of fatalities, injuries, or uninjured: 3 fatalities;
State: GA;
Accident details: An air ambulance helicopter returning to base was
destroyed when it collided with trees and the ground during flight.
Year: 2000;
Flight regulation: 91;
When accident occurred: Day;
Number of fatalities, injuries, or uninjured: 1 uninjured;
State: MN;
Accident details: An air ambulance helicopter departing for refueling
was substantially damaged during takeoff from a hospital helipad during
windy conditions.
Year: 2000;
Flight regulation: 135;
When accident occurred: Day;
Number of fatalities, injuries, or uninjured: 4 injuries;
State: AZ;
Accident details: An air ambulance helicopter attempting to airlift a
seriously injured patient impacted trees and terrain and was
substantially damaged.
Year: 2000;
Flight regulation: 91;
When accident occurred: Night;
Number of fatalities, injuries, or uninjured: 1 fatality;
State: NC;
Accident details: An air ambulance helicopter experiencing mechanical
difficulties collided with terrain and was destroyed. The accident
occurred after a mechanic had taken insufficient action to fix the
problem.
Year: 2000;
Flight regulation: 91;
When accident occurred: Night;
Number of fatalities, injuries, or uninjured: 3 uninjured;
State: NV;
Accident details: An air ambulance helicopter attempting to pick up a
patient at a remote site collided with the ground during an aborted
landing and sustained substantial damage.
Year: 2000;
Flight regulation: 91;
When accident occurred: Night;
Number of fatalities, injuries, or uninjured: 3 injuries;
State: AZ;
Accident details: An air ambulance helicopter on a positioning flight
sustained substantial damage when the pilot became ill and lost control
just before landing.
Year: 2001;
Flight regulation: 91;
When accident occurred: Night;
Number of fatalities, injuries, or uninjured: 1 injury,;
2 uninjured;
State: IL;
Accident details: An air ambulance helicopter readying for takeoff
received minor damage when a hospital security guard walked into the
tail rotor.
Year: 2001;
Flight regulation: 91;
When accident occurred: Day;
Number of fatalities, injuries, or uninjured: 1 fatality;
State: CO;
Accident details: An air ambulance helicopter conducting a
postmaintenance flight check was destroyed when it impacted the ground
after losing rotor speed.
Year: 2001;
Flight regulation: 91;
When accident occurred: Day;
Number of fatalities, injuries, or uninjured: 2 injuries;
State: NY;
Accident details: An air ambulance helicopter on a positioning flight
was substantially damaged during a precautionary landing following a
mechanical malfunction.
Year: 2001;
Flight regulation: 91;
When accident occurred: Day;
Number of fatalities, injuries, or uninjured: 3 uninjured;
State: WY;
Accident details: An air ambulance helicopter conducting an off- site
landing was substantially damaged when its tail rotor impacted a
barrel.
Year: 2001;
Flight regulation: 91;
When accident occurred: Day;
Number of fatalities, injuries, or uninjured: 3 uninjured;
State: AZ;
Accident details: An air ambulance helicopter on a positioning flight
was substantially damaged during a forced landing following a reported
loss of engine power.
Year: 2001;
Flight regulation: 135;
When accident occurred: Day;
Number of fatalities, injuries, or uninjured: 4 uninjured;
State: OR;
Accident details: An air ambulance helicopter departing an off-site
landing zone had to conduct an emergency landing because of a fire in
the aircraft.
Year: 2001;
Flight regulation: 91;
When accident occurred: Day;
Number of fatalities, injuries, or uninjured: 3 injuries;
State: TX;
Accident details: An air ambulance helicopter en route to pick up a
patient was substantially damaged when it impacted trees and terrain
following a loss of engine power.
Year: 2001;
Flight regulation: 135;
When accident occurred: Day;
Number of fatalities, injuries, or uninjured: 4 uninjured;
State: CA;
Accident details: An air ambulance helicopter encountering low
visibility conditions rolled onto its side during takeoff from a remote
location.
Year: 2001;
Flight regulation: 91;
When accident occurred: Night;
Number of fatalities, injuries, or uninjured: 1 fatality,;
1 injury,;
1 uninjured;
State: CA;
Accident details: An air ambulance helicopter attempting to land at an
off-site landing zone was destroyed when it encountered brownout
conditions and collided with trees.
Year: 2001;
Flight regulation: 91;
When accident occurred: Night;
Number of fatalities, injuries, or uninjured: 2 injuries,;
1 uninjured;
State: TX;
Accident details: An air ambulance helicopter on a nighttime
positioning flight was substantially damaged during a hard landing
following a total loss of engine power.
Year: 2001;
Flight regulation: 91;
When accident occurred: Night;
Number of fatalities, injuries, or uninjured: 1 injury;
State: ID;
Accident details: An air ambulance helicopter on a nighttime
repositioning flight was destroyed when it collided with terrain after
the pilot became spatially disoriented.
Year: 2002;
Flight regulation: 91;
When accident occurred: Night;
Number of fatalities, injuries, or uninjured: 2 fatalities,;
1 injury;
State: OH;
Accident details: An air ambulance helicopter was destroyed when it
collided with a brick façade during a takeoff from a rooftop helipad in
windy conditions.
Year: 2002;
Flight regulation: 91;
When accident occurred: Day;
Number of fatalities, injuries, or uninjured: 1 fatality,;
2 injuries;
State: CA;
Accident details: An air ambulance helicopter en route to pick up a
patient was substantially damaged when the pilot became visually
disoriented and collided with the surface of a lake.
Year: 2002;
Flight regulation: 91;
When accident occurred: Night;
Number of fatalities, injuries, or uninjured: 3 uninjured;
State: AR;
Accident details: An air ambulance helicopter was substantially damaged
when its tail rotor struck trees during an approach to a landing zone.
Year: 2002;
Flight regulation: 91;
When accident occurred: Day;
Number of fatalities, injuries, or uninjured: 3 uninjured;
State: FL;
Accident details: An air ambulance helicopter experiencing mechanical
trouble was substantially damaged when it performed a forced landing.
Year: 2002;
Flight regulation: 91;
When accident occurred: Day;
Number of fatalities, injuries, or uninjured: 3 fatalities;
State: NE;
Accident details: An air ambulance helicopter en route to pick up a
patient was destroyed when it experienced a loss of control and a
corresponding collision with terrain.
Year: 2002;
Flight regulation: 135;
When accident occurred: Night;
Number of fatalities, injuries, or uninjured: 5 uninjured;
State: FL;
Accident details: An air ambulance helicopter transporting a patient
had an engine fire and was forced to conduct an emergency landing.
Year: 2002;
Flight regulation: 91;
When accident occurred: Day;
Number of fatalities, injuries, or uninjured: 4 injuries;
State: FL;
Accident details: An air ambulance helicopter en route to pick up a
patient collided with a corner of a multistory parking garage during
takeoff from a hospital helipad.
Year: 2002;
Flight regulation: 91;
When accident occurred: Night;
Number of fatalities, injuries, or uninjured: 3 fatalities;
State: CA;
Accident details: An air ambulance helicopter en route to an accident
scene was destroyed after impacting terrain while maneuvering.
Year: 2002;
Flight regulation: 135;
When accident occurred: Night;
Number of fatalities, injuries, or uninjured: 4 fatalities;
State: SD;
Accident details: An air ambulance helicopter completing a nighttime
interfacility transport crashed into terrain and was destroyed after
the pilot lost control.
Year: 2002;
Flight regulation: 91;
When accident occurred: Day;
Number of fatalities, injuries, or uninjured: 3 uninjured;
State: TX;
Accident details: An air ambulance helicopter sustained substantial
damage following a loss of control while attempting to take off from a
hospital helipad.
Year: 2002;
Flight regulation: 91;
When accident occurred: Day;
Number of fatalities, injuries, or uninjured: 1 uninjured;
State: KY;
Accident details: An air ambulance helicopter experiencing a loss of
control was substantially damaged during an emergency landing at an off-
site landing zone.
Year: 2002;
Flight regulation: 135;
When accident occurred: Day;
Number of fatalities, injuries, or uninjured: 4 uninjured;
State: WA;
Accident details: An air ambulance helicopter, while conducting an
interfacility transport, sustained substantial damage when it
encountered whiteout snow conditions and completed a hard emergency
landing.
Year: 2002;
Flight regulation: 91;
When accident occurred: Night;
Number of fatalities, injuries, or uninjured: 3 uninjured;
State: NY;
Accident details: An air ambulance helicopter was substantially damaged
after encountering a gust of wind during an engine startup on a rooftop
helipad.
Year: 2003;
Flight regulation: 91;
When accident occurred: Night;
Number of fatalities, injuries, or uninjured: 2 fatalities,;
1 injury;
State: UT;
Accident details: An air ambulance helicopter crashed into terrain
after encountering dense fog while on an aborted mission to pick up a
patient.
Year: 2003;
Flight regulation: 91;
When accident occurred: Night;
Number of fatalities, injuries, or uninjured: 1 fatality;
State: IL;
Accident details: An air ambulance helicopter operating in reduced
visibility conditions was destroyed as a result of a collision with
terrain.
Year: 2003;
Flight regulation: 91;
When accident occurred: Day;
Number of fatalities, injuries, or uninjured: 1 injury,;
2 uninjured;
State: TX;
Accident details: An air ambulance helicopter en route to pick up a
patient for interfacility transport sustained substantial damage when
it impacted terrain during a hard landing.
Year: 2003;
Flight regulation: 91;
When accident occurred: Day;
Number of fatalities, injuries, or uninjured: 3 uninjured;
State: TX;
Accident details: An air ambulance helicopter was substantially damaged
after a tail rotor drive failed during flight as a result of a blanket
coming into contact with the tail rotor blades due to an unsecured
cargo door.
Year: 2003;
Flight regulation: 135;
When accident occurred: Night;
Number of fatalities, injuries, or uninjured: 1 uninjured;
State: MI;
Accident details: An air ambulance helicopter at an off-site landing
zone was substantially damaged when the tail rotor impacted a roadway
sign during an aerial taxi.
Year: 2003;
Flight regulation: 91;
When accident occurred: Day;
Number of fatalities, injuries, or uninjured: 3 uninjured;
State: PA;
Accident details: An air ambulance helicopter conducted an emergency
landing because a flashlight left on the tail boom came into contact
with the tail rotor blades.
Year: 2003;
Flight regulation: 91;
When accident occurred: Day;
Number of fatalities, injuries, or uninjured: 1 fatality,;
1 injury,;
1 uninjured;
State: UT;
Accident details: An air ambulance helicopter en route to its home base
after completing a patient transport was destroyed when it impacted a
hillside.
Year: 2003;
Flight regulation: 135;
When accident occurred: Day;
Number of fatalities, injuries, or uninjured: 3 injuries,;
1 uninjured;
State: FL;
Accident details: An air ambulance helicopter crashed while attempting
to take off from an off-site landing zone.
Year: 2003;
Flight regulation: 91;
When accident occurred: Day;
Number of fatalities, injuries, or uninjured: 3 injuries;
State: NY;
Accident details: An air ambulance helicopter was substantially damaged
during a forced landing when the pilot misinterpreted power loss.
Year: 2003;
Flight regulation: 135;
When accident occurred: Day;
Number of fatalities, injuries, or uninjured: 4 uninjured;
State: CA;
Accident details: An air ambulance helicopter in the process of
transporting a patient made an emergency off-airport landing after
experiencing severe in-flight vibrations.
Year: 2003;
Flight regulation: 91;
When accident occurred: Night;
Number of fatalities, injuries, or uninjured: 3 uninjured;
State: IL;
Accident details: An air ambulance helicopter executed a precautionary
landing to a vacant parking lot after the helicopter encountered an in-
flight vibration.
Year: 2003;
Flight regulation: 91;
When accident occurred: Night;
Number of fatalities, injuries, or uninjured: 1 injury,;
2 uninjured;
State: TX;
Accident details: An air ambulance helicopter sustained substantial
damage when it impacted a safety fence and rolled over during an
aborted takeoff following a partial loss of engine power.
Year: 2003;
Flight regulation: 135;
When accident occurred: Night;
Number of fatalities, injuries, or uninjured: 3 uninjured;
State: IN;
Accident details: An air ambulance helicopter sustained substantial
damage during a hard landing in a gravel lot after losing visibility
due to dust.
Year: 2003;
Flight regulation: 135;
When accident occurred: Day;
Number of fatalities, injuries, or uninjured: 4 uninjured;
State: AZ;
Accident details: An air ambulance helicopter transporting a patient
experienced a loss of control due to mechanical failure and crashed on
a taxiway during an emergency landing.
Year: 2003;
Flight regulation: 91;
When accident occurred: Day;
Number of fatalities, injuries, or uninjured: 1 injury;
State: AR;
Accident details: An air ambulance helicopter was substantially damaged
following a loss of control during engine start because the main rotor
was still tied down.
Year: 2003;
Flight regulation: 91;
When accident occurred: Night;
Number of fatalities, injuries, or uninjured: 3 uninjured;
State: TX;
Accident details: An air ambulance helicopter readying for an off-site
landing sustained substantial damage when the tail rotor blades
impacted trees while maneuvering.
Year: 2003;
Flight regulation: 91;
When accident occurred: Night;
Number of fatalities, injuries, or uninjured: 3 uninjured;
State: KY;
Accident details: An air ambulance helicopter landing at an off-site
landing zone was substantially damaged when its tail rotor struck a
hydrant that had not been identified by ground personnel.
Year: 2003;
Flight regulation: 91;
When accident occurred: Night;
Number of fatalities, injuries, or uninjured: 3 fatalities;
State: CA;
Accident details: An air ambulance helicopter on the way to pick up a
patient crashed into mountainous terrain during high winds and heavy
rain.
Year: 2004;
Flight regulation: 135;
When accident occurred: Night;
Number of fatalities, injuries, or uninjured: 4 fatalities,;
1 injury;
State: TX;
Accident details: An air ambulance helicopter transporting a patient
crashed into terrain while maneuvering in reduced visibility.
Year: 2004;
Flight regulation: 135;
When accident occurred: Night;
Number of fatalities, injuries, or uninjured: 1 fatality,;
3 injuries;
State: IN;
Accident details: An air ambulance helicopter transporting a patient
was substantially damaged when it collided with terrain.
Year: 2004;
Flight regulation: 91;
When accident occurred: Day;
Number of fatalities, injuries, or uninjured: 3 uninjured;
State: TX;
Accident details: An air ambulance helicopter sustained substantial
damage when its tail rotor struck a parked helicopter while hovering
prior to takeoff from a helipad.
Year: 2004;
Flight regulation: 91;
When accident occurred: Day;
Number of fatalities, injuries, or uninjured: 3 uninjured;
State: AZ;
Accident details: An air ambulance helicopter landing at an off- site
landing zone was substantially damaged after a hard landing in low
visibility conditions.
Year: 2004;
Flight regulation: 135;
When accident occurred: Night;
Number of fatalities, injuries, or uninjured: 4 fatalities;
State: SC;
Accident details: An air ambulance helicopter flying in mist and light
fog collided with trees shortly after picking up a patient at an
Interstate accident site.
Year: 2004;
Flight regulation: 135;
When accident occurred: Day;
Number of fatalities, injuries, or uninjured: 4 uninjured;
State: ID;
Accident details: An air ambulance helicopter was substantially damaged
while maneuvering at an accident site during windy conditions.
Year: 2004;
Flight regulation: 135;
When accident occurred: Night;
Number of fatalities, injuries, or uninjured: 5 fatalities;
State: NV;
Accident details: An air ambulance helicopter crashed into mountainous
terrain at night and in deteriorating weather conditions.
Year: 2004;
Flight regulation: 91;
When accident occurred: Night;
Number of fatalities, injuries, or uninjured: 1 injury;
State: NM;
Accident details: An air ambulance helicopter on a positioning flight
was substantially damaged after liftoff when the helicopter's skid
struck the helipad and caused the helicopter to roll over.
Year: 2004;
Flight regulation: 91;
When accident occurred: Night;
Number of fatalities, injuries, or uninjured: 3 fatalities;
State: FL;
Accident details: An air ambulance helicopter attempting to return to
base after abandoning a mission due to bad weather was destroyed when
it crashed into water.
Year: 2004;
Flight regulation: 91;
When accident occurred: Day;
Number of fatalities, injuries, or uninjured: 3 uninjured;
State: AZ;
Accident details: An air ambulance helicopter flying to pick up a
patient experienced a partial power loss, followed by a hard landing in
a parking lot.
Year: 2004;
Flight regulation: 135;
When accident occurred: Night;
Number of fatalities, injuries, or uninjured: 2 injuries,;
1 uninjured;
State: OK;
Accident details: An air ambulance helicopter was substantially damaged
when it impacted terrain following a loss of control due to a blanket
coming in contact with the tail rotor blades during flight.
Year: 2004;
Flight regulation: 91;
When accident occurred: Night;
Number of fatalities, injuries, or uninjured: 1 fatality,;
2 injuries;
State: AZ;
Accident details: An air ambulance helicopter was destroyed when it
collided with terrain while attempting to land at an off-site landing
zone.
Year: 2005;
Flight regulation: 91;
When accident occurred: Day;
Number of fatalities, injuries, or uninjured: 1 injury,;
1 uninjured;
State: AZ;
Accident details: An air ambulance helicopter readying to land at an
airport experienced loss of control and collided with terrain.
Year: 2005;
Flight regulation: 91;
When accident occurred: Night;
Number of fatalities, injuries, or uninjured: 1 fatality;
State: MS;
Accident details: An air ambulance helicopter was destroyed after
colliding with trees and the ground in adverse weather conditions.
Year: 2005;
Flight regulation: 91;
When accident occurred: Night;
Number of fatalities, injuries, or uninjured: 2 fatalities,;
1 injury;
State: MD;
Accident details: An air ambulance helicopter returning to base was
destroyed after impacting water.
Year: 2005;
Flight regulation: 135;
When accident occurred: Day;
Number of fatalities, injuries, or uninjured: 1 fatality,;
3 injuries;
State: AR;
Accident details: An air ambulance helicopter transporting a patient
lost control and was substantially damaged during a hard landing.
Year: 2005;
Flight regulation: 91;
When accident occurred: Day;
Number of fatalities, injuries, or uninjured: 3 fatalities;
State: CO;
Accident details: An air ambulance helicopter was substantially damaged
when it impacted terrain while approaching an off-site landing zone.
Year: 2005;
Flight regulation: 135;
When accident occurred: Day;
Number of fatalities, injuries, or uninjured: 4 uninjured;
State: IN;
Accident details: An air ambulance helicopter was substantially damaged
following an in-flight loss of control after it impacted the helipad
after takeoff.
Year: 2005;
Flight regulation: 91;
When accident occurred: Day;
Number of fatalities, injuries, or uninjured: 3 uninjured;
State: FL;
Accident details: An air ambulance helicopter sustained substantial
damage when it rolled over while conducting an emergency landing after
takeoff.
Year: 2005;
Flight regulation: 91;
When accident occurred: Night;
Number of fatalities, injuries, or uninjured: 3 fatalities;
State: WA;
Accident details: An air ambulance helicopter was destroyed when it
impacted ocean waters while returning to base.
Year: 2005;
Flight regulation: 91;
When accident occurred: Night;
Number of fatalities, injuries, or uninjured: 1 fatality;
State: PA;
Accident details: An air ambulance helicopter on a refueling flight was
destroyed when it impacted trees and terrain while performing an
instrument approach to the airport.
Year: 2005;
Flight regulation: 135;
When accident occurred: Night;
Number of fatalities, injuries, or uninjured: 1 injury,;
3 uninjured;
State: WA;
Accident details: An air ambulance helicopter during takeoff sustained
substantial damage after impacting an object and subsequently impacting
terrain.
Year: 2005;
Flight regulation: 91;
When accident occurred: Day;
Number of fatalities, injuries, or uninjured: 3 uninjured;
State: MN;
Accident details: An air ambulance helicopter sustained substantial
damage during an aborted takeoff after a loss of power.
Source: GAO analysis of NTSB data.
[End of table]
[End of section]
Appendix III Comments from the Association of Air Medical Services:
Association of Air Medical Services:
526 King Street:
Suite 415:
Alexandria, VA 22314-3143:
(703) 836-8732:
FAX (703) 836-8920:
www.aams.org:
February 6, 2007:
Dr. Gerald L. Dillingham:
Director of Civil Aviation Issues:
U.S. Government Accountability Office:
441 G St. NW, Room 2T23B:
Washington, DC 20548:
RE: GAO Report on Air Medical Services:
Dear Dr. Dillingham:
The Association of Air Medical Services (AAMS) thanks the Government
Accountability Office (GAO) for the opportunity to comment on this
report, and we commend the members of the GAO research team for all of
their efforts to continually engage the air medical community in the
course of their research. The entire investigation process was
conducted in an open and professional manner from the onset. We believe
that this spirit of openness and cooperation led to an excellent
report, despite the limited time the investigative team had to study
and understand the complexities of the air medical community and its
importance in providing timely patient care and transport.
Overall, AAMS supports the recommendations made in the GAO Report on
Air Medical Services. It is our belief that increased data collection
in the air medical community, and in the aviation community as a whole,
will lead to better research and a much more focused understanding of
the importance of air medical services and the need for a more robust
infrastructure to support this vital service. While AAMS does support
the recommendations and commends the GAO for their diligence, we also
take this opportunity to clarify several issues presented in the report
in order to provide the most accurate information possible.
Background:
The Association of Air Medical Services (AAMS) is a non-profit trade
association representing air ambulance and critical care transport
service providers in the U.S. and across the globe. AAMS is comprised
of over 300 air medical transport provider programs in the United
States and Canada, staffed with over 50,000 highly skilled crew members
(including medical directors, flight physicians, transport nurses,
flight paramedics, helicopter and fixed wing pilots, mechanics,
administrators and others) who have dedicated themselves to improving
the health outcomes of the patients we serve.
Air medicine has become a critically important part of our nation's
health care delivery system, not only because air ambulance providers
offer an ability to provide time-sensitive care, but also because their
highly skilled crews and technologically advanced equipment allow them
to provide a higher level of patient care ell-route than what is
normally available via ground medical transport. Every 90 seconds, an
air medical provider in the U.S. responds to a request to assist a
critically ill or injured patient with a medically equipped and
dedicated aircraft.
AAMS and its members are firmly committed to assuring the public of
access to this essential medical service while maintaining the highest
level of safety in the delivery of patient care. To meet that
commitment, AAMS and its members have worked extensively and
collaboratively with the Federal Aviation Administration (FAA)
Helicopter Emergency Medical Services (HEMS) Task Force and other
regulatory entities in an effort to foster an environment that promotes
a safe and effective air medical system. We firmly believe that this
cooperative effort, combined with numerous safety initiatives of the
air medical community, has led to a dramatic decrease in the number of
HEMS accidents in 2006.
Current Trends in the Air Medical Community:
The air medical community is cognizant of and dedicated to the need for
more thorough data collection, and to that end created the Atlas and
Database of Air Medical Services (ADAMS), a voluntary database of air
medical locations and other information which is referenced numerous
times in the GAO's report. Support for ADAMS is provided by the US
Department of Transportation (through the Federal Highway
Administration and the National Highway Traffic Safety Administration).
Through the voluntary reporting efforts of AAMS members, that database
now represents the only accurate source for the locations,
capabilities, and service areas for air medical programs and bases.
This service is also being used by numerous government agencies,
including the Department of Homeland Security, and remains the only
source for information of this type.
While the ADAMS database has become an excellent tool, it is also a
voluntary database, and is therefore flawed when viewed from a
historical perspective. Because it is a voluntary database, it is
impossible to compare the number of helicopter services from 2003 (the
first year of reporting into the database) and 2005 because those
numbers may only reflect an increase in the number of companies and
programs reporting into the database, not an actual increase in
existing aircraft and service locations. While there is no doubt that
the use of air medical services as a mode of patient transport has
increased steadily throughout the community's history, the actual
increase in numbers in the database is not completely reliable over
time.
It is equally problematic to compare the number of accidents in a
certain period to the number of accidents in a different period;
specifically, the number of accidents that occurred in the air medical
industry in 1985 to the number of accidents that occurred in 2005.
While the number of accidents is similar, the number of aircraft and
hours being flown is dramatically different; in fact, AAMS estimates
that the numbers of both aircraft and flight hours have increased ten
fold from 1985 to 2005. So, while there can be no specific
determination of an accident rate due to the fact that the data is not
available in the aggregate, we can easily surmise that an estimated ten-
fold increase in both aircraft and flight hours with a similar number
of accidents between 1985 and 2005 illustrates an industry with a
vastly improved safety record over time.
Air Medical Community Safety Initiatives:
This is not to say, however, that there is any acceptable number of
accidents in the air medical community. To that end, AAMS has
instituted a number of safety-focused initiatives since 2000 as a way
for our community to voluntarily address these issues.
For instance, AAMS launched its Vision Zero initiative in March of 2005
(www.aams.visionzero.or g). Vision Zero signifies zero accidents of
consequence; it is our community's safety program designed to promote
safety awareness by reaching the community with timely information and
educational opportunities. Vision Zero, since its inception, has
greatly increased safety awareness by creating a culture of intolerance
to the loss of life and the suffering caused by the consequences of
poor decision-making. It is a message that is carried through every
conference, committee meeting, education session, and program activity
carried out by the air medical community. We only hope to enhance the
visibility and effectiveness of this program in the future.
AAMS has also joined the International Helicopter Safety
Team(www.ihst.org ), led by the American Helicopter Society (AHS), the
Helicopter Association International (HAI), the FAA, and Transport
Canada, to reduce helicopter accidents. These efforts are premised on
the model that providers must work collaboratively with regulators to
identify and accelerate the implementation of best practice standards,
and they are both very closely coordinated with the work done by the
FAA's HEMS Safety Task Force.
AAMS represented the air medical community during the Part 135 Aviation
Rulemaking Committee (ARC), the FAA's effort to engage the aviation
industry during a re-write of Part 135 of the Federal Aviation
Regulations (FAA's). The AAMS representatives sat on the steering
committee and chaired the air medical subcommittee. The recommendations
made by this group to the ARC included making all segments of a flight
fall under the Part 135 regulations for rest and duty time and weather
minima. It was also recommended to the ARC at that time to revise the
existing Part 135 regulations to allow flights flying under Instrument
Flight Rules (IFR) to off airport destinations without NWS approved
weather stations. This change in the regulation would eliminate the
need for any segment of a HEMS flight to operate under Part 91 as the
current exemption requires. At present, the Part 135 ARC
recommendations are being considered within the FAA for possible
incorporation into regulatory changes.
AAMS believes these examples, as well as our other initiatives, provide
a faster, more flexible, and a more comprehensive means to improving
safety. In an era in which both providers and regulators are working in
increasingly resource-constrained environments, a collaborative, data
driven strategy is essential. AAMS welcomes efforts to track these
efforts and report on their efficacy.
We further believe that the combination of these initiatives, a closely
coordinated and cooperative effort, has led to the recent dramatic
downturn of accidents in 2006, in which only three HEMS accidents
occurred. While we firmly believe that any accident rate is
unacceptable, we do believe that this dramatic decrease in the number
of accidents is the direct result of the steps taken by the air medical
community to improve safe operations.
Improving Data Collection Concerning Air Medical Services:
Improving the safety of medicine and medical transportation is a
complex undertaking and cannot be studied in isolation. Air medicine
must be seen as both a portion of the aviation community and as a
necessary part of our medical system. Significant gaps in available
data resources are evident and are a severe detriment to research
efforts both from a medical and an aviation perspective. AAMS would
like to support the GAO's recommendations in order to help the air
medical community fill those gaps. Given the unique nature of and
diverse models for the delivery of air medical transport in our country
today, we recommend that any data collection effort involve all service
providers - hospital-based services, independent services and
government-operated services - in order to present a balanced and
comprehensive picture of the community.
Several AAMS members, often working through the non-profit Foundation
for Air Medical Research and Education (FARE), conduct numerous
research projects in order to determine what safety tools would be most
effective. We firmly believe that these recommendations by the GAO can
only help bolster the existing research and data-collection efforts and
help provide the air medical community with the most valuable tools to
improve and maintain safe operations.
AAMS has also initiated, with the cooperation of the National Emergency
Medical Services Operators Executive Forum, the voluntary collection of
flight hour and other aviation data through a similar process as the
collection of the ADAMS data. This data will be collected through the
Center for Transportation and Injury Research and reported to the
public in the aggregate. This program, dubbed the Flight Operations
Database for Air Medical Services (FODAMS), is still in its infancy and
the data could not be used for the purposes of this report. However, it
is important to note that the air medical community has long recognized
the importance of quality data, and has undertaken, through numerous
efforts, the collection of this data voluntarily.
AAMS and the air medical community are committed to improving safety of
medicine and aviation; keeping those goals in mind, we also must
continue to care for critically ill and injured patients every day. In
our efforts to improve, we must not put more lives at risk by
decreasing access to care.
Air Medical Services as Part of the Emergency Medical System:
While there are numerous flaws in the voluntary reporting of the data,
there can be no doubt that the number of air medical services and
medically equipped aircraft has increased, specifically in the last
five years. Much of the growth in air medical services reflects a
changing emergency healthcare system: as medical centers close
emergency departments and trauma centers, especially in rural areas,
the need for air transportation of the sickest and most badly injured
patients greatly increases. The decreasing availability of specialized
surgical resources, especially neurological, cardiac, and pediatric
specialists, also drives the need for air medical transport, as time
and distance to appropriate care have increased for large segments of
our population.
The Institute of Medicine (IOM) recently completed a landmark study of
the emergency healthcare system in the United States, a portion of
which is dedicated to our nation's emergency medical system. That
report, entitled The Future of Emergency Care: Emergency Medical
Services at the Crossroads highlights the necessity of air medical
services in the emergency medical system, focusing on the ability of
the HEMS to provide patient transport when time is of the essence. The
report also highlights the growing necessity of the use of air medical
services in inter-facility transport, moving severely injured or very
ill patients to more appropriate specialty healthcare centers where
they can be treated properly.
The Institute of Medicine's report cited a study that claimed over 81
million Americans now depend on air medical resources to reach needed
care within the "golden hour" for trauma, cardiac, and other time
sensitive emergencies, and over 40 million Americans who live in very
rural areas remain underserved in the face of these time critical
emergencies. It is clearly evident that air medical services now
provide a critical access point in what many consider to be a failing
medical system While we can only estimate the numbers of patients
transported and cared for every year, or the amount of flight hours
that were performed in the course of this operation, we can say with
certainty that air medical transport has become a necessary and vital
part of the medical system, both here in the United States and in many
countries around the world. Medically equipped aircraft and specialized
flight crews trained to meet the air medical mission are expensive
investments that would not exist unless driven by a medical need; the
changing emergency and specialized healthcare system in the United
States is what provides that need.
Air medical services have also played a key role in disaster response
and emergency preparedness, transporting patients from the Pentagon
following the 9/11 disaster, and more recently responding to Hurricanes
Katrina and Rita in 2005. As noted in the US House of Representatives
Final Report of the Select Bipartisan Committee to Investigate the
Preparation for and Response to Hurricane Katrina, entitled A Failure
of Initiative, air medical services were instrumental in much of the
most critical hospital evacuations, especially in instances where
hospitals were inaccessible by ground EMS providers. Over 60 civilian
air medical helicopters transported thousands of affected citizens
after Hurricane Katrina, despite the fact that there was a lack of
communication and federal coordination of civilian aviation assets.
Commercial air medical helicopters provide over 80% of the medical
airlift capacity in our country, and are thus uniquely designed and
equipped to address national emergencies involving very sick and
critically injured patients. These aircraft are also very well suited
to transporting critical patients out of a disaster area before the
event occurs, as evidenced by the pre-evacuations to Hurricane Rita and
the numerous hurricane responses in the state of Florida in which air
medical helicopters are utilized both before and after a disastrous
event.
Transport medicine is among the most complex arenas of medicine,
characterized by a dichotomy in which access to time sensitive care for
critically ill and injured patients must be immediately available,
often with limited planning time conducted in hostile environmental
conditions. As Justice Oliver Wendell Holmes once noted: "to be safe
does not mean to be risk free." Recognizing that risk cannot be
completely eliminated, it is essential both for the public we serve,
and the pilots, nurses, paramedics, physicians, and other health care
providers who deliver care, that the practice environment be as safe as
practically possible. AAMS and the air medical community remain
committed to this ideal.
AAMS would again like to thank the GAO for the opportunity to offer
comments on this report. We also recognize and thank the Subcommittee
on Aviation for their continued vigilance over the safety of the
public, and we look forward to providing any further information that
might be needed regarding our nation's critically important air medical
mission.
Sincerely,
Signed by:
Edward R. Eroe, CHE, CAE, CMTE:
President, AAMS & Partner & CEO:
MedServ Air Medical Transport, LLC Platte City, Missouri:
Signed by:
Dawn M. Mancuso, MAM, CAE:
Executive Director/CEO:
AAMS:
[End of section]
Appendix IV: GAO Contact and Staff Acknowledgments:
GAO Contact:
Gerald L. Dillingham, Ph.D., (202) 512-2834 or dillinghamg@gao.gov:
Staff Acknowledgments:
In addition to the contact named above, Nikki Clowers, Assistant
Director; Ashley Alley; David Hooper; Brooke Leary; Heather MacLeod;
Mitchell Karpman; Sara Ann Moessbauer; Stan Stenersen; Friendly Vang-
Johnson; and Pamela Vines made key contributions to this report.
(540123):
FOOTNOTES
[1] Such direct air carriers must also obtain an exemption from the
Department of Transportation's economic regulatory authority, which is
provided under 14 CFR Part 298.
[2] For the purposes of this report, the use of the term "operator"
refers to the FAA certificate holder.
[3] Other types of operations include services that are operated by
government entities or the military. For example, the Maryland State
Police Aviation Division has a comprehensive helicopter air ambulance
capability that covers the entire state, while the California Highway
Patrol provides air ambulance services in portions of California. In
addition to these public-use operators, federally operated aircraft
provided by the U.S. Coast Guard and the U.S. Army conduct civilian air
ambulance operations in select states. It is estimated that 10 percent
of air ambulance operations in the United States are publicly operated.
FAA does not have direct safety oversight responsibilities for public-
use and military aircraft, and therefore, we did not include
information on these types of operations in this report.
[4] A hospital, or other non airline entity, may hold an exemption from
DOT's economic authority to operate as an "indirect air carrier" (an
entity that does not actually operate aircraft) to sell air ambulance
air transport services directly to the public as a principal and, in
turn, contract with a properly licensed airline for the air
transportation. A blanket exemption authorizing such operations was
issued in 1983 by the Civil Aeronautics Board, DOT's predecessor. Such
indirect air carriers may not, however, mislead the public into
thinking that they are airlines, which has been emphasized to the
industry through a letter from DOT's Office of Aviation Enforcement to
the Association of Air Medical Services.
[5] Operating Requirements: Commuter and On Demand Operations and Rules
Governing Persons on Board Such Aircraft, 14 C.F.R. pt. 135 (2006).
[6] General Operating and Flight Rules, 14 C.F.R. pt. 91 (2006).
[7] According to FAA officials, while Part 91 repositioning flights are
not directly governed by Part 135 flight duty and rest requirements,
there is little, if any, negative effect.
[8] National Transportation Safety Board, Special Investigative Report
on Emergency Medical Services Operations (Washington, D.C., 2006).
[9] National Transportation Safety Board, Safety Study: Commercial
Emergency Medical Services Helicopter Operations (Washington, D.C.,
1988).
[10] AAMS is a nonprofit international association that serves
providers of air and surface medical transport systems.
[11] The Atlas and Database of Air Medical Services is compiled by
CUBRC's Center for Transportation Injury Research in alliance with AAMS
and the air medical industry, with support from the Federal Highway
Administration and the National Highway Traffic Safety Administration.
We did not independently assess the accuracy of these data for the
purposes of this study. See appendix I for more information.
[12] GAATAA is an annual survey of a sample of Part 135 on-demand and
general aviation operators. FAA uses the survey data to evaluate the
impact of safety initiatives and regulatory changes and for other
purposes.
[13] NTSB has previously recommended FAA require activity reporting for
all Part 135 operators.
[14] Based on the methodologies used, we recognize limitations with the
estimates of flight hours, and our presentation is for the purposes of
showing the wide range of estimates and the uncertainty associated with
these estimates. Therefore, we did not assess the reliability of FAA or
other estimates of flight hours for the purposes of this report.
[15] Ira J. Blumen, M.D., and the University of Chicago Aeromedical
Network, A Safety Review and Risk Assessment in Air Medical Transport:
Supplement to the Air Medical Physician Handbook (November 2002). The
methodology used in this study was updated in a follow-up study to
include the nine largest air ambulance operators in the United States.
For more information, see I.J. Blumen and D. Lees, "Air Medical Safety:
Your First Priority," Principles and Direction of Air Medical Transport
(Salt Lake City, Utah: Air Medical Physician Association, September
2006).
[16] For more information, see Bart Elias, Congressional Research
Service, The Safety of Air Ambulances (Washington, D.C., 2006); and
Matthew J. Rigsby, FAA, U.S. Civil Helicopter Emergency Medical
Services Accident Data Analysis, the FAA Perspective (September 2005).
[17] FARE's mission is to support the charitable, educational and
research purposes of AAMS.
[18] Balanced Budget Act of 1997, P.L. No. 105-33, § 4523 (Aug. 5,
1997).
[19] Bryan E. Bledsoe, "Thank You for Not Flying," Air and Space
Journal (June/July 2006).
[20] In 2006, FAA issued a letter to all state Emergency Medical
Services Directors (or equivalent positions) describing "helicopter
shopping" and requesting that the directors take action within their
jurisdiction to implement standards and procedures to prohibit this
practice.
[21] NTSB defines an aviation accident as "an occurrence associated
with the operation of an aircraft which takes place between the time
any person boards the aircraft with the intention of flight and all
such persons have disembarked, and in which any person suffers death or
serious injury, or in which the aircraft receives substantial damage."
An accident was included in the analysis as a helicopter air ambulance
accident if (1) the accident involved a helicopter being operated by an
air medical transport company and (2) the accident occurred during
flight under either Part 91 or Part 135 regulations. All accidents
involving public operators were excluded from our analysis. See
appendixes I and II for more information about the accidents used in
this analysis.
[22] NTSB categorizes accidents by the highest level of injury
sustained; therefore, accidents in which fatalities occurred could also
include serious injuries, minor injuries, or no injuries.
[23] Crew resource management is the effective management of resources
to ensure that group members are operating from a common frame of
reference and toward a common goal of safety.
[24] The FAA also applies specific limitations and requirements for
Part 135 operators through the use of operations specifications, which
are individually developed for each operator.
[25] Our analysis of NTSB data from 1998 through 2005 included 89 air
ambulance helicopter accidents and 1,129 non-air-ambulance helicopter
accidents.
[26] FAA requires certificate holders to maintain a process for
operational control of their aircraft. FAA officials noted that
operational control should be (1) independent from the clinical or
medical side of management and operations, (2) dictated solely by
criteria such as weather and operational capability of crew and
equipment, and (3) managed exclusively by the certificate holder.
[27] For more information, see Matthew J. Rigsby, FAA, U.S. Civil
Helicopter Emergency Medical Services Accident Data Analysis, the FAA
Perspective (September 2005).
[28] GAO, Aviation Safety: FAA Management Practices for Technical
Training Mostly Effective; Further Actions Could Enhance Results, GAO-
05-728 (Washington, D.C.: Sept. 7, 2005).
[29] FAA is shifting the oversight of commercial airlines (Part 121
carriers) to a new system--the Air Transportation Oversight System--and
as part of this realignment is restructuring the resources for
geographic oversight. This restructuring may affect the availability of
geographic resources for air ambulance oversight.
[30] GAO, Aviation Safety: FAA's Safety Oversight System Is Effective
but Could Benefit from Better Evaluation of Its Programs' Performance,
GAO-06-266T (Washington, D.C.: Nov. 17, 2005).
[31] Our analysis of NTSB accident data (see app. II) showed that more
accidents occurred under Part 91 flight rules. However, because more
flights take place under Part 91 rules, it is difficult to tie the
accident record of Part 91 and Part 135 flights to safety.
[32] FAA is considering a request from an air ambulance operator to
perform instrument flight rules departures and approach procedures at
airports and helipads that do not have an approved weather reporting
source. If this exemption to current Part 135 rules is approved by FAA,
this operator would be able to fly in accordance with instrument flight
rules more often and, according to the operator, thereby improve the
safety of its Part 135 flights.
[33] SEP is used by FAA in its oversight of commuter air carriers and
is considered to be a more effective and efficient surveillance program
than traditional, event-based surveillance. SEP emphasizes a system
safety approach of using risk analysis techniques and allows FAA
inspectors to prioritize workload based on areas of highest risk. For
more information on SEP, see GAO, Aviation Safety: System Safety
Approach Needs Further Integration into FAA's Oversight of Airlines,
GAO-05-726 (Washington, D.C.: Sept. 28, 2005).
[34] FAA district offices have initiated hiring efforts to staff to
target levels.
[35] For the other large operators, inspection team sizes were
increased from three nondedicated inspectors to four dedicated
inspectors.
[36] According to NTSB, as of December 21, 2006, these recommendations
are still open.
[37] NTSB, Current Procedures for Collecting and Reporting U.S. General
Aviation Accident and Activity Data Safety Report (Washington, D.C.,
April 2005).
[38] There is no clear consensus about what constitutes an air
ambulance accident; thus, other studies may present different accident
totals covering the same time period.
[39] Large air ambulance markets were determined by state using the
total number of bases and aircrafts as identified in the Atlas and
Database of Air Medical Services. After states had been identified as
having the greatest number of bases and aircrafts, metropolitan regions
were chosen on the basis of having the greatest number of operators
present in the area.
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