Aviation Safety
Potential Strategies to Address Air Ambulance Safety Concerns Gao ID: GAO-09-627T April 22, 2009Air ambulance transport is widely regarded as improving the chances of survival for trauma victims and other critical patients. However, recent increases in the number of air ambulance accidents have led to greater industry scrutiny by government agencies, the public, the media, and the industry itself. The National Transportation Safety Board (NTSB) and others have called on the Federal Aviation Administration (FAA), which provides safety oversight, to issue more stringent safety requirements for the industry. This testimony discusses (1) recent trends in the air ambulance industry with regard to its size, composition, and safety record; (2) recent industry and government efforts to improve air ambulance safety; and (3) potential strategies for improving air ambulance safety. This testimony is based primarily on GAO's February 2007 study on air ambulance safety (GAO-07-353). To update and supplement this 2007 report, GAO analyzed the latest safety information from NTSB and FAA, reviewed published literature on the state of the air ambulance industry, and interviewed FAA officials and industry representatives. GAO provided a copy of the draft testimony statement to FAA. FAA provided technical comments, which GAO incorporated as appropriate.
The air ambulance industry has increased in size, and concerns about its safety have grown in recent years. Available data suggest that the industry grew, most notably in the number of stand alone (independent or community-based) as opposed to hospital-based operators, and competition increased among operators, from 2003 through 2008. During this period, the number of air ambulance accidents remained at historical levels, fluctuating between 11 and 15 accidents per year, and in 2008, the number of fatal accidents peaked at 9. This accident record is cause for concern. However, a lack of reliable data on flight hours precludes calculation of the industry accident rate--a critical piece of information in determining whether the increased number of accidents reflects industry growth or a declining safety record. The air ambulance industry and FAA have acted to address accident trends and causes. For example, FAA enhanced its oversight to reflect the varying sizes of operators, provided technical resources to the industry, launched an accident mitigation program, and revised the minimum standards for weather and safe cruising altitudes that apply to air ambulance operations. Despite the actions to improve air ambulance safety, 2008 was the deadliest year on record for the industry. Through its work on aviation safety, including air ambulance safety; review of the published literature; and interviews with government and industry officials, GAO has identified several potential strategies for improving air ambulance safety, including the following: (1) Obtain complete and accurate data on air ambulance operations. (2) Increase the use of safety technologies. (3) Sustain recent efforts to improve air ambulance safety. (4) Fully address NTSB's recommendations. (5) Adopt safety management systems within the air ambulance industry. (6) Clarify the role of states in overseeing air medical services. (7) Determine the appropriate use of air ambulance services.
GAO-09-627T, Aviation Safety: Potential Strategies to Address Air Ambulance Safety Concerns
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Testimony:
Before the Subcommittee on Aviation, Committee on Transportation and
Infrastructure, House of Representatives:
United States Government Accountability Office:
GAO:
For Release on Delivery:
Expected at 10:00 a.m. EDT:
Wednesday, April 22, 2009:
Aviation Safety:
Potential Strategies to Address Air Ambulance Safety Concerns:
Statement of Gerald L. Dillingham, Ph.D.
Director, Physical Infrastructure Issues:
GAO-09-627T:
GAO Highlights:
Highlights of GAO-09-627T, a testimony before the 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,
recent increases in the number of air ambulance accidents have led to
greater industry scrutiny by government agencies, the public, the
media, and the industry itself. The National Transportation Safety
Board (NTSB) and others have called on the Federal Aviation
Administration (FAA), which provides safety oversight, to issue more
stringent safety requirements for the industry.
This testimony discusses (1) recent trends in the air ambulance
industry with regard to its size, composition, and safety record; (2)
recent industry and government efforts to improve air ambulance safety;
and (3) potential strategies for improving air ambulance safety. This
testimony is based primarily on GAO‘s February 2007 study on air
ambulance safety (GAO-07-353). To update and supplement this 2007
report, GAO analyzed the latest safety information from NTSB and FAA,
reviewed published literature on the state of the air ambulance
industry, and interviewed FAA officials and industry representatives.
GAO provided a copy of the draft testimony statement to FAA. FAA
provided technical comments, which GAO incorporated as appropriate.
What GAO Found:
The air ambulance industry has increased in size, and concerns about
its safety have grown in recent years. Available data suggest that the
industry grew, most notably in the number of stand alone (independent
or community-based) as opposed to hospital-based operators, and
competition increased among operators, from 2003 through 2008. During
this period, the number of air ambulance accidents remained at
historical levels, fluctuating between 11 and 15 accidents per year,
and in 2008, the number of fatal accidents peaked at 9. This accident
record is cause for concern. However, a lack of reliable data on flight
hours precludes calculation of the industry accident rate”a critical
piece of information in determining whether the increased number of
accidents reflects industry growth or a declining safety record.
The air ambulance industry and FAA have acted to address accident
trends and causes. For example, FAA enhanced its oversight to reflect
the varying sizes of operators, provided technical resources to the
industry, launched an accident mitigation program, and revised the
minimum standards for weather and safe cruising altitudes that apply to
air ambulance operations.
Despite the actions to improve air ambulance safety, 2008 was the
deadliest year on record for the industry. Through its work on aviation
safety, including air ambulance safety; review of the published
literature; and interviews with government and industry officials, GAO
has identified several potential strategies for improving air ambulance
safety, including the following:
* Obtain complete and accurate data on air ambulance operations.
* Increase the use of safety technologies.
* Sustain recent efforts to improve air ambulance safety.
* Fully address NTSB‘s recommendations.
* Adopt safety management systems within the air ambulance industry.
* Clarify the role of states in overseeing air medical services.
* Determine the appropriate use of air ambulance services.
Figure: Air Ambulance Helicopters:
[Refer to PDF for image: two photographs]
Source: FEMA and Washington State Department of Health.
[End of figure]
[End of section]
Mr. Chairman and Members of the Subcommittee:
I appreciate the opportunity to testify before you today on air
ambulance safety. My remarks will focus on (1) recent trends in the air
ambulance industry with regard to size, composition, and safety record;
(2) recent industry and government efforts to improve air ambulance
safety; and (3) potential strategies for improving air ambulance
safety. My testimony is based primarily on our February 2007 report on
air ambulance safety, which we conducted at the request of the
Chairman.[Footnote 1] To update and supplement our existing work, we
analyzed the latest safety information from the National Transportation
Safety Board (NTSB) and the Federal Aviation Administration (FAA),
reviewed published literature on the state of the air ambulance
industry, and interviewed officials from NTSB and FAA and industry
representatives.[Footnote 2] We conducted this work in March and April
2009.
Background:
Air ambulances are an integral part of U.S. emergency medical systems,
primarily transporting patients between hospitals, but also providing
transport from accident scenes or for organs, medical supplies, and
specialty medical teams. Air ambulances may be helicopters or fixed-
wing aircraft. Helicopter air ambulances provide on-scene responses and
much of the shorter-distance hospital-to-hospital transport, while
fixed-wing aircraft are used mainly for longer facility-to-facility
transport. (See figure 1.) Helicopter air ambulances make up about 74
percent of the air ambulance fleet and, unlike fixed-wing aircraft, do
not always operate under the direction of air traffic controllers. They
also often operate in challenging conditions, flying, for example, at
night during inclement weather and using makeshift landing zones at
remote sites. My testimony today focuses on the safety of helicopter
air ambulance operations.
Figure 1: Air Ambulance Helicopter:
[Refer to PDF for image: photograph]
Source: Clare McLean © 2006.
[End of figure]
Air ambulance operations can take many different forms but are
generally one of two business models--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. The hospital pays
the operator for services supplied.[Footnote 4] In a stand-alone
(independent or community-based) 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 either
employs both the medical and flight crews or contracts with an aviation
services provider for them. This stand-alone model carries more
financial risk for the operator because revenues depend solely on
payments for transporting patients. Some operators provide both
hospital-based and stand-alone services and may have bases located over
wide geographic areas.
Regardless of the business model employed, most air ambulances--except
government and military aircraft--must operate under rules specified in
Part 135 of Title 14 of the Code of Federal Regulations when patients
are on board and may operate under rules specified in Part 91 when
patients are not present. As a result, different legs of air ambulance
missions may be flown under different rules. However, some operators
fly under part 135 regardless of whether patients are on board the
aircraft. (See figure 2.) Flight rules under Parts 91 and 135 differ in
two key areas--(1) minimum requirements for weather and visibility and
(2) rest requirements for pilots. The Part 135 requirements are more
stringent.
Figure 2: Air Ambulance Scene Response Flight Legs:
[Refer to PDF for image: illustration]
Hospital:
* Reposition (Part 91);
* En Route (Part 91);
* Transport (Part 135).
Source: GAO.
Note: Flight rules under Parts 91 and 135 differ in two key areas--(1)
minimum requirements for weather and visibility and (2) rest
requirements for pilots. The Part 135 requirements are more stringent.
[End of figure]
Industry Has Expanded and Safety Concerns Have Grown in Recent Years:
Available Data Suggest Industry Growth and Increased Competition:
According to industry experts and observers, the air ambulance industry
has grown, but data limitations make it difficult to determine by how
much. Data for several years on the 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
the Association of Air Medical Services (AAMS).[Footnote 5] For 2003,
the first year for which data are available, AAMS members reported a
total of 545 helicopters stationed at 472 bases (airports, hospitals,
and helipads). By 2008, the number of helicopters listed in the
database had grown to 840, an increase of 54 percent, and the number of
bases had grown to 699, an increase of 48 percent (see fig. 3). While a
database official said that the data partly reflect the use of a
revised criterion that allowed for the inclusion of more helicopters
and for improved reporting since the database was established, the
increase also reflects actual growth.
Figure 3: Number of Air Ambulance Bases and Aircraft, 2003 through
2008:
[Refer to PDF for image: multiple vertical bar graph]
Year: 2003;
Bases: 472;
Aircraft: 545.
Year: 2004;
Bases: 546;
Aircraft: 658.
Year: 2005;
Bases: 614;
Aircraft: 753.
Year: 2006;
Bases: 647;
Aircraft: 792.
Year: 2007;
Bases: 664;
Aircraft: 810.
Year: 2008;
Bases: 699;
Aircraft: 840.
Source: GAO analysis of Association of Air Medical Services, Atlas and
Database of Air Medical Services data.
[End of figure]
Data are less readily available on whether this increase number of
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 operators regulated
under Part 135 are not required to report flight activity data to FAA
or the Department of Transportation.[Footnote 6] Historically, FAA
estimated the number of flight hours, using responses to its annual
General Aviation and Air Taxi and Avionics (GAATAA) survey. These
estimates may not be reliable, however, because the survey is based on
a sample of aircraft owners and response rates have historically been
low.
According to the government and industry officials we interviewed and
the literature we reviewed, most of the air ambulance industry's growth
has been in the stand-alone (independent) provider business model.
[Footnote 7] Testimony from industry stakeholders recently submitted to
NTSB further identifies the stand-alone provider business model as the
current area of industry growth. The growth in the stand-alone provider
business model has led to increased competition in some locales.
According to the officials we interviewed and others who have studied
the industry, the increase in the stand-alone provider business model
is linked to the development, mandated in 1997, of a Medicare fee
schedule for ambulance transports, which has increased the potential
for profit making.[Footnote 8] This 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.[Footnote 9] Because the fee schedule has created the
potential for higher and more certain revenues, competition has
increased in certain areas, according to many of our sources.
Increased competition can lead to potentially unsafe practices,
industry experts said. Although we were unable to determine how
widespread these activities are, experts cited the potential for such
practices, including helicopter shopping and call jumping. Helicopter
shopping refers to calling a series of operators until an operator
agrees to take a flight assignment, without telling the subsequently
called operators why the previously called operators declined the
flight. This practice can be unsafe if the operator that accepts the
flight assignment is not aware of all of the facts surrounding the
assignment.[Footnote 10] Call jumping occurs when an air ambulance
operator responds to a scene without being dispatched to it 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 at night or in marginal weather
conditions--increasing the risk of a midair collision or other
accident.
Industry Experienced Highest Number of Fatal Accidents in 2008, but
Data Limitations Preclude Complete Understanding of Safety Record:
From 1998 through 2008, the air ambulance industry averaged 13
accidents per year, according to NTSB data.[Footnote 11] The annual
number of air ambulance accidents increased from 8 in 1998 to a high of
19 in 2003. Since 2003, the number of accidents has slightly declined,
fluctuating between 11 and 15 accidents per year. While the total
number of air ambulance accidents peaked in 2003, the number of fatal
accidents peaked in 2008, when 9 fatal accidents occurred (see fig. 4).
Of 141 accidents that occurred from 1998 to 2008, 48 accidents resulted
in the deaths of 128 people. From 1998 through 2007, the air ambulance
industry averaged 10 fatalities per year. The number of overall
fatalities increased sharply in 2008, however, to 29.
Figure 4: Fatal and Non-fatal Air Ambulance Accidents, 1998-2008:
[Refer to PDF for image: multiple line graph]
Year: 1998;
Fatal accidents: 4;
Non-fatal accidents: 4.
Year: 1999;
Fatal accidents: 3;
Non-fatal accidents: 6.
Year: 2000;
Fatal accidents: 4;
Non-fatal accidents: 9.
Year: 2001;
Fatal accidents: 2;
Non-fatal accidents: 12.
Year: 2002;
Fatal accidents: 5;
Non-fatal accidents: 8.
Year: 2003;
Fatal accidents: 4;
Non-fatal accidents: 15.
Year: 2004;
Fatal accidents: 6;
Non-fatal accidents: 7.
Year: 2005;
Fatal accidents: 6;
Non-fatal accidents: 9.
Year: 2006;
Fatal accidents: 3;
Non-fatal accidents: 10.
Year: 2007;
Fatal accidents: 2;
Non-fatal accidents: 8.
Year: 2008;
Fatal accidents: 9;
Non-fatal accidents: 2.
Source: GAO analysis of NTSB data.
Note: These numbers include accidents of public-use aircraft as well as
additional accidents for 1998 through 2005 that NTSB included in its
totals after revising its definition of an air ambulance accident.
[End of figure]
Both the spike in the number of fatal accidents in 2008 and the overall
number of accidents are a cause for concern. However, given the
apparent growth in the industry, the increase in the number of
accidents may not indicate that the industry has experienced, on the
whole, the industry's safety record has worsened. More specifically,
without actual data on the number of hours flown, no accident rate can
be accurately calculated. Because an accurate accident rate is
important to a complete understanding of the industry's safety, we
recommended in 2007 that FAA collect data on flight activity, including
flight hours.[Footnote 12] In response, FAA has surveyed all helicopter
air ambulance operators to collect flight activity data. However, to
date, FAA's survey response rate is low, raising questions about
whether this information can serve as an accurate measure or indicator
of flight activity.
In the absence of actual flight activity data, others have attempted to
estimate flight hours and accident rates for the industry. For example,
an Air Medical Physician Association (AMPA) study estimated annual
flight hours for the air medical industry through an operator survey,
determining that the overall air medical helicopter accident rate has
dropped slightly in recent years to approximately 3 accidents per
100,000 flight hours.[Footnote 13] However, the study's preliminary
estimates for 2008 indicate that the fatal accident rate tripled over
the 2007 rate, increasing from 0.54 fatal accidents per 100,000 flight
hours in 2007 to 1.8 fatal accidents per 100,000 flight hours in 2008.
Data on the causes and factors underlying air ambulance accidents
indicate that while the majority of accidents are caused by pilot
error, a number of risks, including nighttime operations, adverse
weather conditions, and flights to remote sites, also contribute to
accidents. NTSB data on helicopter accidents occurring from 1998
through 2008 show that pilot error was deemed the probable cause in
more than 70 percent of air ambulance accidents, while factors related
to flight environment (such as light, weather, and terrain) contributed
to 54 percent of all accidents.[Footnote 14] Nighttime accidents for
air ambulance helicopters were prevalent, and air ambulance accidents
tended to be more severe when they occurred at night than during the
day. Similarly, air ambulance accidents were often associated with
adverse weather conditions (e.g., wind gust and fog). Finally, flying
to remote sites may further expose the crew to other risks associated
with unfamiliar topography and makeshift landing sites.
Industry and FAA Have Acted to Address Air Ambulance Accident Trends
and Causes:
Increase in Number of Accidents Has Led to Greater Industry Focus on
Safety:
In 2007, we reported that the air ambulance industry's response to the
higher number of accidents has taken a variety of forms, including
research into accident causes and training.[Footnote 15] Since then,
the industry has continued its focus on improving safety by, for
example, initiating efforts to develop an industry risk profile and
share weather information. In July 2008, for instance, AAMS convened a
conference (summit) on safety to encourage open communication between
the medical and aviation sectors of the industry. AAMS plans to issue a
summary of the summit's proceedings that will include recommended next
steps. Table 1 highlights examples of recent industry initiatives.
Table 1: Examples of Recent Air Ambulance Industry Initiatives to
Address Safety Concerns:
Year: 2007;
Organization: AirMed International LLC;
Initiative: Administers the Web Site WeatherTurndown.com, which allows
medical transport programs to share current information on delays or
cancellations due to weather.
Year: 2008;
Organization: AAMS;
Initiative: Safety summit with operators, regulators, medical
professionals, and insurance providers to discuss and learn from recent
accidents.
Year: 2008;
Organization: Commission on the Accreditation of Medical Transport
Systems (CAMTS); Initiative: Produced and distributed a video on
"helicopter shopping," which can lead to an unsafe condition in which
an operator initiates a flight that it may have declined if it had been
told that other operators had turned down the flight for safety
reasons.
Year: 2008; Organization: Bell Helicopter; Initiative: Sponsored safety
risk profile of the industry..
Year: 2009;
Organization: Air Medical Operators Association (AMOA), AAMS, and
Helicopter Association International; Initiative: Developed and
submitted recommendations to NTSB that are intended to enhance air
medical safety.
Source: GAO.
[End of table]
FAA Has Taken a Number of Actions to Address Safety Concerns:
In 2007, we reported that FAA, the primary federal agency overseeing
air ambulance operators, has issued guidance, expanded inspection
resources, and collaborated with the industry to reduce the number of
air ambulance accidents. Since then, FAA has taken additional steps to
improve air ambulance safety including the following:
* Enhanced oversight to better reflect the unique nature of the
industry. FAA has changed its oversight to reflect the varying sizes of
operators. Specifically, large operators with 25 or more helicopters
dedicated to air medical flights are now assigned to dedicated FAA
Certificate Management Teams (CMT)--groups of inspectors that are
assigned to one air ambulance operator. These CMTs range in size from 4
inspectors for Keystone Helicopter Corporation, which has a fleet of 38
helicopters, to 24 inspectors for Air Methods, which has a fleet of 322
helicopters. Additionally, CMTs use a data-and risk-based process to
target inspections to areas that pose greater safety risk. For
operators of all sizes, FAA has asked inspectors to consider using the
Surveillance Priority Index tool, which can be used to identify an
operator's most pressing safety hazards. In addition, FAA is hiring
more aviation safety inspectors with rotorcraft experience.
* Provided technical resources. FAA has revised its guidance for the
use of night vision goggles (NVG) and established a cadre of NVG
national resource inspectors.[Footnote 16] FAA has also developed
technical standards for the manufacture of helicopter terrain awareness
and warning systems for air medical helicopters.[Footnote 17] These
standards articulate the minimum performance standards and
documentation requirements that the technology must meet to obtain FAA
approval. FAA also commissioned the development of an air ambulance
weather tool, which provides weather assessments for the community.
[Footnote 18]
* Launched accident mitigation program. Initiated in January 2009, this
program provides guidance for inspectors of air ambulance operators,
requiring them to ensure, among other things, that these operators have
a process in place to facilitate safe operations, such as a risk
assessment program.
* Revised minimum standards for weather and safe cruise altitudes: To
enhance safety, FAA revised its minimal requirements for weather and
safe cruise altitudes for helicopter air ambulances in November 2008.
[Footnote 19] Specifically, FAA revised its specifications to require
that if a patient is on board for a flight or flight segment and at
least one of the flight segments is therefore subject to Part 135
rules, then all of the flight segments must be conducted within the
revised weather minimums and above a minimum safe cruise altitude
determined in preflight planning.
* Issued guidance on operational control: To help operators better
assess risk, improve the flow of information before and during flights,
and increase support for flight operations, FAA issued guidance to help
air medical operators develop, implement, and integrate operations
control centers and enhance operational control procedures.[Footnote
20]
To date, FAA has opted not to use its rulemaking authority to require
certain actions, relying instead on notices and guidance to encourage
air ambulance operators to take certain actions. FAA guidance and
notices are not mandatory for air ambulance operators and are not
subject to enforcement. FAA officials told us that rulemaking 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. However, we previously noted
that FAA lacked information on the extent to which air ambulance
operators were implementing the agency's voluntary guidance and on the
effect such guidance was having. Consequently, we recommended that FAA
collect information on operators' implementation of the voluntary
guidance and evaluate the effectiveness of that guidance. In response,
in January 2009, FAA directed safety inspectors to survey the air
medical operators they oversee about their adoption of suggested
practices, such as implementing risk assessment programs and developing
operations control centers.[Footnote 21] According to the inspectors,
most of the 74 operators surveyed said they had adopted these
practices.
Potential Strategies for Improving Air Ambulance Safety:
Despite the actions taken by the industry and the federal government,
2008 was the deadliest year on record for the air ambulance industry.
As a board member noted at the recent NTSB hearing on air ambulance
safety, the recent accident record of the industry is unacceptable.
Based on our body of work on aviation safety, including air ambulance
safety; a review of the published literature; and interviews with
government and industry officials, we have identified several potential
strategies for improving air ambulance safety. Each of these strategies
has merits and challenges, and we have not analyzed their benefits and
costs. But, as the recent accident numbers show, additional efforts are
warranted.
* Obtain complete and accurate data on air ambulance operations: As we
reported in 2007, FAA lacks basic industry information, such as the
number of flights and flight hours. In response to our prior
recommendation that FAA collect flight activity data, FAA surveyed all
helicopter air ambulance operators in 2008, but fewer than 40 percent
responded, thereby raising questions about the reliability of the
information collected. The low response rate also suggests that many
operators will not provide this information unless they are required to
do so. Until FAA obtains complete and reliable information from all air
ambulance operators, it will be unable to gain a complete understanding
of the industry and determine whether its efforts to improve industry
safety are sufficient and accurately targeted.
* Increase use of safety technologies: We have previously reported that
using appropriate technology and infrastructure can help improve
aviation safety.[Footnote 22] For example, the development and
installation of terrain awareness and warning systems on large
passenger carriers has almost completely eliminated controlled flights
into terrain,[Footnote 23] particularly for aircraft equipped with this
system. When we studied the air ambulance industry in 2006 and 2007,
the most frequently cited helicopter-appropriate technology was night
vision goggles. Additional safety technology has been developed or is
in development that will help aircraft avoid cables and enhance terrain
awareness for pilots, among other things. However, testimony submitted
by industry stakeholders at NTSB's February 2009 hearing on air
ambulance safety indicated that the implementation of such technology
has been slow. NTSB previously recommended that FAA require terrain
awareness and warning systems on air ambulances. Proposed legislation
(H.R. 1201) would also require FAA to complete a study within one year
of the date of enactment on the feasibility of requiring flight data
and cockpit voice recorders on new and existing air ambulances.
[Footnote 24]
* Sustain recent efforts to improve air ambulance safety: Our past
aviation safety work and anecdotal information on air ambulance
accident trends suggest that the industry and federal government must
sustain recent efforts to improve air ambulance safety. In 1988, after
the number of accidents increased in the mid-1980s, NTSB published a
study that examined air ambulance safety issues.[Footnote 25] The study
contained 19 safety recommendations to FAA and others. FAA took action,
including implementing the NTSB recommendations, and the number of
ambulance accidents declined in the years that immediately
followed.[Footnote 26] However, as time passed, the number of accidents
started to increase, peaking in 2003. This again triggered a flurry of
government and industry actions. Similarly, FAA took steps to address
runway incursions and overruns after the number and rate of incursions
peaked in fiscal year 2001, but FAA's efforts later waned, and the
number and rate of incursions and overruns remained steady. [Footnote
27]
* Fully Address NTSB recommendations: In 2006, NTSB published a special
report focusing on the air ambulance industry, which included four
recommendations to FAA to improve air ambulance safety.[Footnote 28]
Specifically, NTSB called for FAA to (1) require that all flights with
medical personnel on board be conducted in accordance with Part 135
regulations, (2) develop and implement flight risk evaluation programs,
(3) require formalized dispatch and flight-following procedures, and
(4) require terrain awareness and warning systems on aircraft. As of
January 2009, FAA had sufficiently addressed only the recommendation to
require formalized dispatch and flight-following procedures, according
to NTSB. However, NTSB's February 2009 air ambulance hearing
highlighted the status of the NTSB recommendations, and major industry
associations have said they agree in principle with the
recommendations, but would like to work with FAA and NTSB to adapt the
recommendations to the industry's circumstances and gain more
flexibility. Proposed legislation (H.R. 1201) also would require most
of the safety enhancements NTSB recommended.
* Adopt safety management systems within the air ambulance industry:
Air operators rely on a number of protocols to help reduce the
potential for poor or erroneous judgment, but evidence suggests that
these protocols may be inconsistently implemented or followed in air
ambulance operations. According to an FAA report on air ambulance
accidents from 1998 through 2004, a lack of operational control
(authority over initiating, conducting, and terminating a flight) and
poor aeronautical decision making were significant factors contributing
to these accidents.[Footnote 29] To combat such issues, FAA has been
encouraging air ambulance operators to move toward adopting safety
management systems, providing guidance, developing a generic flight
risk assessment tool for operators, and requiring inspectors to promote
the adoption of safety best practices.
* Clarify the role of states in overseeing air ambulance services: Air
ambulance industry stakeholders disagree on the role that states should
play in overseeing broader aspects of air medical operations. In
particular, some industry stakeholders have advocated a greater role
for states in regulating air ambulance services as part of their public
health function. Other industry stakeholders, however, oppose increased
state oversight, noting, for example, that the Airline Deregulation Act
explicitly prohibits states from regulating the price, route, or
service of an air carrier. This legislation generally limits oversight
at the state or local levels to the medical care and equipment provided
by air ambulance services, although the extent of this oversight varies
by state. Proposed legislation (H.R. 978) would recognize and clarify
the authority of the states to regulate intrastate air ambulance
services in accordance with their authority over public health.
[Footnote 30]
* Determine the appropriate use of air ambulance services: According to
a May 2007 article by two physicians, multiple organizations are
concerned that air ambulance services are overused and misused.
[Footnote 31] The study further notes concerns that decisions about
where to transport a patient may be influenced by nonmedical reasons,
such as insurance coverage or agreements with hospitals. Another
industry expert has posited that excessive use of air ambulances may be
unsafe and not beneficial for most patients, citing recent studies that
conclude few air transport patients benefited significantly over
patients transported by ground and noting the recent increase in the
number of air medical accidents. Other studies, however, have disagreed
with this position, citing reductions in mortality achieved by using
air ambulances to quickly transport critically injured patients.
Agency Comments:
We provided a draft copy of this testimony to FAA for review and
comment. FAA provided technical clarifications, which we incorporated
as appropriate.
Mr. Chairman, this concludes my prepared statement. I would be pleased
to respond to questions from you or other Members of the Subcommittee.
GAO Contact and Staff Acknowledgments:
For further information on this statement, please contact Dr. Gerald L.
Dillingham at (202) 512-2834 or dillinghamg@gao.gov. Contact points for
our Congressional Relations and Public Affairs offices may be found on
the last page of this statement. Individuals making key contributions
to this testimony were Nikki Clowers, Assistant Director; Vashun Cole,
Elizabeth Eisenstadt, Brooke Leary, and Pamela Vines.
[End of section]
Footnotes:
[1] GAO, Aviation Safety: Improved Data Collection Needed for Effective
Oversight of Air Ambulance Industry, [hyperlink,
http://www.gao.gov/products/GAO-07-353] (Washington, D.C.: Feb. 21,
2007). This review and our updated work was conducted in accordance
with generally accepted government auditing standards.
[2] FAA is the federal agency responsible for providing aviation safety
oversight in the United States and NTSB is an independent federal
agency charged with investigating each U.S. aviation accident.
[3] Other types of operations include services that are operated by
government entities or the military.
[4] A hospital, or other nonairline entity, may hold an exemption from
the Department of Transportation to operate as an "indirect air
carrier," that is, an entity that does not actually operate aircraft,
to sell air ambulance air services to the public and contract with a
licensed airline for the air transportation.
[5] AAMS is a nonprofit international association that serves providers
of air and medical transport systems.
[6] NTSB previously recommended that FAA require flight activity
reporting for all Part 135 operators.
[7] For example, a 2006 public policy paper by the Foundation for Air
Medical Research & Education (FARE) observed that many air medical
services "had become independent, community based resources."
Similarly, a 2005 FAA research paper noted that "the fastest growing
segment of the [air medical] industry is the independent provider.
[8] Balanced Budget Act of 1997, P.L. No. 105-33, § 4523 (Aug. 5,
1997).
[9] Prior to 2002, all ambulance service reimbursements by Medicare
were based on the type of provider.
[10] For example, in July 2004, an air ambulance collided with trees
shortly after take-off, killing the pilot, flight nurse, flight
paramedic, and patient. Three other air ambulance operators had
previously turned down this same flight, including one that had
attempted it but was forced to return because of fog. The pilot during
the accident, however, was not informed by emergency medical service
dispatchers that other pilots had declined the flight because of
adverse weather conditions. 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.
[11] NTSB has revised its definition of an air ambulance accident since
our 2007 report to include accidents with an aircraft (1) dedicated to
air medical operations, (2) configured for such operations, and (3)
piloted by a dedicated air medical flight crew. Consequently, the
numbers of accidents presented in this testimony for 1998 through 2005
is slightly higher than those presented in our 2007 report.
[12] [hyperlink, http://www.gao.gov/products/GAO-07-353].
[13] 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.
To determine flight hours, the study's author multiplied the average
flight hours per program by the total number of programs identified in
each year. 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). The methodology was further expanded
following the 2006 study to include nearly 20 operators, representing a
reported 90 percent of air medical helicopters in the United States.
I.J. Blumen, "An Analysis of HEMS Accidents and Accident Rates"
(Washington, D.C.: NTSB public hearing: Safety of Helicopter Emergency
Medical Services Operations, February, 2009). We interviewed Dr. Blumen
about the study's methodology and findings. We determined that the
study's methodology and findings were sufficiently reliable for our
purposes.
[14] Numbers do not add to 100 percent because multiple factors could
contribute to a single accident. Some 2008 accidents were excluded from
this analysis because NTSB has not yet completed their accident
investigations and made determinations of cause and underlying factors.
[15] For more information on the industry safety initiatives we
identified, see [hyperlink, http://www.gao.gov/products/GAO-07-353].
[16] See FAA Order 8900.1 and Notice 8000.349.
[17] TSO-C194, December 17, 2008.
[18] Developed as a result of FAA's 2006 air ambulance weather summit,
the air ambulance weather tool provides assessments of ceilings and
visibility for a given time and location. It does not report
observations or forecasts and currently can only be used in visual
flight rule operations to determine whether to initiate a flight.
[19] 73 Fed. Reg. 6754, Nov. 14, 2008.
[20] Advisory Circular 120-96.
[21] See FAA Notice 8900.63.
[22] GAO, Aviation Runway and Ramp Safety: Sustained Efforts to Address
Leadership, Technology, and Other Challenges Needed to Reduce Accidents
and Incidents, [hyperlink, http://www.gao.gov/products/GAO-08-29]
(Washington, D.C.: Nov. 20, 2007.
[23] Controlled flight into terrain occurs when an airworthy aircraft
under the control of the flight crew is flown unintentionally into
terrain, obstacles or water, usually with no prior awareness by the
crew.
[24] H.R. 1201, "Air Medical Safety Act." The bill would also require a
complete rulemaking within 30 months requiring flight data and cockpit
voice recorders on board air ambulances.
[25] NTSB, Safety Study: Commercial Emergency Medical Services
Helicopter Operations (Washington, D.C.: 1988).
[26] Because of the lack of flight activity data and the number of
other factors that could affect accident trends, we do not know to what
extent, if at all, FAA's actions contributed to the decline in the
number of accidents.
[27] [hyperlink, http://www.gao.gov/products/GAO-08-29].
[28] National Transportation Safety Board, Special Investigative Report
on Emergency Medical Services Operations (Washington, D.C., 2006).
[29] For more information, see Matthew J. Rigsby, FAA, U.S. Civil
Helicopter Emergency Medical Services Accident Data Analysis, the FAA
Perspective (September 2005).
[30] H.R. 978, "Helicopter Medical Services Patient Safety, Protection,
and Coordination Act."
[31] Mary E. Fallat, MD, FACS, and John Overton, MD et al, "Air Medical
Transport Safety," Bulletin of the American College of Surgeons, May
2007.
[End of section]
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