[House Hearing, 111 Congress]
[From the U.S. Government Publishing Office]
OVERSIGHT OF HELICOPTER MEDICAL SERVICES
=======================================================================
(111-23)
HEARING
BEFORE THE
SUBCOMMITTEE ON
AVIATION
OF THE
COMMITTEE ON
TRANSPORTATION AND INFRASTRUCTURE
HOUSE OF REPRESENTATIVES
ONE HUNDRED ELEVENTH CONGRESS
FIRST SESSION
----------
APRIL 22, 2009
----------
Printed for the use of the
Committee on Transportation and Infrastructure
OVERSIGHT OF HELICOPTER MEDICAL SERVICES
OVERSIGHT OF HELICOPTER MEDICAL SERVICES
=======================================================================
(111-23)
HEARING
BEFORE THE
SUBCOMMITTEE ON
AVIATION
OF THE
COMMITTEE ON
TRANSPORTATION AND INFRASTRUCTURE
HOUSE OF REPRESENTATIVES
ONE HUNDRED ELEVENTH CONGRESS
FIRST SESSION
__________
APRIL 22, 2009
__________
Printed for the use of the
Committee on Transportation and Infrastructure
----------
U.S. GOVERNMENT PRINTING OFFICE
49-001 PDF WASHINGTON : 2009
For sale by the Superintendent of Documents, U.S. Government Printing
Office Internet: bookstore.gpo.gov Phone: toll free (866) 512-1800;
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Washington, DC 20402-0001
COMMITTEE ON TRANSPORTATION AND INFRASTRUCTURE
JAMES L. OBERSTAR, Minnesota, Chairman
NICK J. RAHALL, II, West Virginia, JOHN L. MICA, Florida
Vice Chair DON YOUNG, Alaska
PETER A. DeFAZIO, Oregon THOMAS E. PETRI, Wisconsin
JERRY F. COSTELLO, Illinois HOWARD COBLE, North Carolina
ELEANOR HOLMES NORTON, District of JOHN J. DUNCAN, Jr., Tennessee
Columbia VERNON J. EHLERS, Michigan
JERROLD NADLER, New York FRANK A. LoBIONDO, New Jersey
CORRINE BROWN, Florida JERRY MORAN, Kansas
BOB FILNER, California GARY G. MILLER, California
EDDIE BERNICE JOHNSON, Texas HENRY E. BROWN, Jr., South
GENE TAYLOR, Mississippi Carolina
ELIJAH E. CUMMINGS, Maryland TIMOTHY V. JOHNSON, Illinois
LEONARD L. BOSWELL, Iowa TODD RUSSELL PLATTS, Pennsylvania
TIM HOLDEN, Pennsylvania SAM GRAVES, Missouri
BRIAN BAIRD, Washington BILL SHUSTER, Pennsylvania
RICK LARSEN, Washington JOHN BOOZMAN, Arkansas
MICHAEL E. CAPUANO, Massachusetts SHELLEY MOORE CAPITO, West
TIMOTHY H. BISHOP, New York Virginia
MICHAEL H. MICHAUD, Maine JIM GERLACH, Pennsylvania
RUSS CARNAHAN, Missouri MARIO DIAZ-BALART, Florida
GRACE F. NAPOLITANO, California CHARLES W. DENT, Pennsylvania
DANIEL LIPINSKI, Illinois CONNIE MACK, Florida
MAZIE K. HIRONO, Hawaii LYNN A WESTMORELAND, Georgia
JASON ALTMIRE, Pennsylvania JEAN SCHMIDT, Ohio
TIMOTHY J. WALZ, Minnesota CANDICE S. MILLER, Michigan
HEATH SHULER, North Carolina MARY FALLIN, Oklahoma
MICHAEL A. ARCURI, New York VERN BUCHANAN, Florida
HARRY E. MITCHELL, Arizona ROBERT E. LATTA, Ohio
CHRISTOPHER P. CARNEY, Pennsylvania BRETT GUTHRIE, Kentucky
JOHN J. HALL, New York ANH ``JOSEPH'' CAO, Louisiana
STEVE KAGEN, Wisconsin AARON SCHOCK, Illinois
STEVE COHEN, Tennessee PETE OLSON, Texas
LAURA A. RICHARDSON, California
ALBIO SIRES, New Jersey
DONNA F. EDWARDS, Maryland
SOLOMON P. ORTIZ, Texas
PHIL HARE, Illinois
JOHN A. BOCCIERI, Ohio
MARK H. SCHAUER, Michigan
BETSY MARKEY, Colorado
PARKER GRIFFITH, Alabama
MICHAEL E. McMAHON, New York
THOMAS S. P. PERRIELLO, Virginia
DINA TITUS, Nevada
HARRY TEAGUE, New Mexico
VACANCY
(ii)
Subcommittee on Aviation
JERRY F. COSTELLO, Illinois, Chairman
RUSS CARNAHAN, Missouri THOMAS E. PETRI, Wisconsin
PARKER GRIFFITH, Alabama HOWARD COBLE, North Carolina
MICHAEL E. McMAHON, New York JOHN J. DUNCAN, Jr., Tennessee
PETER A. DeFAZIO, Oregon VERNON J. EHLERS, Michigan
ELEANOR HOLMES NORTON, District of FRANK A. LoBIONDO, New Jersey
Columbia JERRY MORAN, Kansas
BOB FILNER, California SAM GRAVES, Missouri
EDDIE BERNICE JOHNSON, Texas JOHN BOOZMAN, Arkansas
LEONARD L. BOSWELL, Iowa SHELLEY MOORE CAPITO, West
TIM HOLDEN, Pennsylvania Virginia
MICHAEL E. CAPUANO, Massachusetts JIM GERLACH, Pennsylvania
DANIEL LIPINSKI, Illinois CHARLES W. DENT, Pennsylvania
MAZIE K. HIRONO, Hawaii CONNIE MACK, Florida
HARRY E. MITCHELL, Arizona LYNN A. WESTMORELAND, Georgia
JOHN J. HALL, New York JEAN SCHMIDT, Ohio
STEVE COHEN, Tennessee MARY FALLIN, Oklahoma
LAURA A. RICHARDSON, California VERN BUCHANAN, Florida
JOHN A. BOCCIERI, Ohio BRETT GUTHRIE, Kentucky
NICK J. RAHALL, II, West Virginia
CORRINE BROWN, Florida
ELIJAH E. CUMMINGS, Maryland
JASON ALTMIRE, Pennsylvania
SOLOMON P. ORTIZ, Texas
MARK H. SCHAUER, Michigan
VACANCY
JAMES L. OBERSTAR, Minnesota
(Ex Officio)
(iii)
CONTENTS
Page
Summary of Subject Matter........................................ vii
TESTIMONY
Allen, John, Director, Flight Standards Service, Federal Aviation
Administration................................................. 12
Bass, Dr. Robert, Chair, Air Medical Committee, the National
Association of State EMS Officials............................. 30
Dillingham, Dr. Gerald, Director, Physical Infrastructure Issues,
U.S. Government Accountability Office.......................... 12
Fornarotto, Hon. Christa, Acting Assistant Secretary for Aviation
and International Affairs, U.S. Department of Transportation... 12
Frazer, RN, CMTE, Eileen, Executive Director, Commission on
Accreditation of Medical Transport Systems..................... 30
Friedman, Stacey, Founder, SafeMedFlight: Family Advocates For
Air Medical Safety............................................. 30
Judge, EMTP, Thomas P., Executive Director, LifeFlight of Maine,
Chair, the Patient First Air-Ambulance Alliance................ 30
Kinkade, Sandra, President, Association of Air Medical Services.. 30
Salazar, Hon. John T., a Representative in Congress from the
State of Colorado.............................................. 10
Stackpole, Jeff, Council Member, Professional Helicopter Pilots
Association.................................................... 30
Sumwalt, III, Hon. Robert L., Board Member, National
Transportation Safety Board.................................... 12
Yale, Craig, Executive Vice President, Air Methods Corporation,
on Behalf of the Air Medical Operators Association............. 30
Zuccaro, Matthew S., President, Helicopter Association
International.................................................. 30
PREPARED STATEMENTS SUBMITTED BY MEMBERS OF CONGRESS
Carnahan, Hon. Russ, of Missouri................................. 47
Costello, Hon. Jerry F., of Illinois............................. 48
Johnson, Hon. Eddie Bernice, of Texas............................ 56
Mitchell, Hon. Harry E., of Arizona.............................. 60
Oberstar, Hon. James L., of Minnesota............................ 61
Salazar, Hon. John T., of Colorado............................... 65
PREPARED STATEMENTS SUBMITTED BY WITNESSES
Allen, John and Hon. Christa Fornarotto, joint statement......... 69
Bass, Dr. Robert................................................. 90
Dillingham, Dr. Gerald........................................... 96
Frazer, RN, CMTE, Eileen......................................... 124
Friedman, Stacey................................................. 138
Judge, EMTP, Thomas P............................................ 149
Kinkade, Sandra.................................................. 187
Stackpole, Jeff.................................................. 202
Sumwalt, III, Hon. Robert L...................................... 214
Yale, Craig...................................................... 229
Zuccaro, Matthew S............................................... 260
SUBMISSIONS FOR THE RECORD
Allen, John, Director, Flight Standards Service, Federal Aviation
Administration, responses to questions from the Subcommittee... 80
Dillingham, Dr. Gerald, Director, Physical Infrastructure Issues,
U.S. Government Accountability Office, responses to questions
from the Subcommittee.......................................... 117
Fornarotto, Hon. Christa, Acting Assistant Secretary for Aviation
and International Affairs, U.S. Department of Transportation,
responses to questions from the Subcommittee................... 85
Judge, EMTP, Thomas P., Executive Director, LifeFlight of Maine,
Chair, the Patient First Air-Ambulance Alliance, responses to
questions from Rep. Costello................................... 161
Sumwalt, III, Hon. Robert L., Board Member, National
Transportation Safety Board, responses to questions from the
Subcommittee................................................... 224
Yale, Craig, Executive Vice President, Air Methods Corporation,
on Behalf of the Air Medical Operators Association, responses
to questions from the Subcommittee............................. 251
ADDITIONS TO THE RECORD
Bean, Danielle, written statement................................ 267
Brady, Laurie, written statement................................. 271
McGlew, Susan, written statement................................. 273
National EMS Pilots Association, Kent Johnson, President, written
statement...................................................... 275
Schiller, Brian T., written statement............................ 311
Schumm, Tracy, written statement................................. 314
Terry, Cece, written statement................................... 316
[GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]
HEARING ON OVERSIGHT OF HELICOPTER MEDICAL SERVICES
----------
Wednesday, April 22, 2009
House of Representatives
Committee on Transportation and Infrastructure,
Subcommittee on Aviation,
Washington, DC.
The Subcommittee met, pursuant to call, at 10:00 a.m., in
Room 2167, Rayburn House Office Building, the Honorable Jerry
F. Costello [chairman of the Subcommittee] presiding.
Mr. Costello. The Subcommittee will come to order. The
Chair will ask all Members, staff, and everyone in the room to
turn electronic devices off or on vibrate.
The purpose of the hearing is to hear testimony on the
oversight of helicopter medical services. We have a number of
witnesses today, two panels, that I hope other Members will be
here to hear their testimony and to ask questions.
We have on our first panel one of our colleagues, a Member
of the House, that will be testifying, the Honorable John
Salazar, from Colorado's 3rd District.
I will offer an opening statement. I will ask, then, the
Ranking Member of the Full Committee to give his opening
statement and the Ranking Member of the Subcommittee.
I welcome everyone to the Aviation Subcommittee hearing
today on oversight of the helicopter medical services. This
hearing will examine two issues: first, the safety of
helicopter emergency medical services, or helicopter EMS; and,
second, the State regulation of helicopter EMS.
The Federal Aviation Administration regulates helicopter
and the pilot, while States regulate the medical care that a
patient receives while on board the aircraft. This hearing is
an opportunity to discuss how the aviation industry,
government, and the health care community can work together
towards a common goal of enhanced helicopter EMS safety.
The helicopter EMS industry provides an important service
by transporting seriously ill patients to emergency care
facilities and high level trauma centers. However, helicopter
air ambulance operates in challenging conditions, such as
flying in bad weather, going into unfamiliar landing sites, and
operating at night.
According to the National Transportation Safety Board,
approximately 400,000 patients and transplant organs each year
are safely transported by helicopter, saving countless lives.
Unfortunately, lives have been lost as well. Between 1998 and
2008, there were 146 helicopter EMS accidents, with 131
fatalities, the greatest number of accidents in any 11 month
period occurring between December 2007 and October 2008
resulting in 13 accidents and 35 fatalities.
I want to acknowledge the family members of those who lost
their lives in helicopter EMS accidents who are here with us
today. On behalf of this Subcommittee and each of our Members,
I offer our condolences.
In 1988, the NTSB conducted a study of helicopter EMS and
issued 19 safety recommendations. In January 2006, 18 years
later, the NTSB conducted another special investigation after
an increase in accidents. As a result of this investigation,
the NTSB issued four safety recommendations to the FAA and
added helicopter EMS to its most wanted list in 2009.
The NTSB also held a four-day public hearing on helicopter
EMS operations in February. I look forward to hearing our NTSB
witness explain the recommendations of its four-day hearing. I
want a progress report on how the FAA plans to proceed
following that hearing, what the agency is doing to address the
safety issues that were raised.
I look forward to an update on the Government
Accountability, the GAO 2007 report that I requested, which
recommended that the FAA identify and collect data to better
understand the air ambulance industry. Without this data, it
would be difficult to know how to address the problem.
In addition, Congressman Salazar and Congressman Lungren
introduced legislation addressing many helicopter EMS safety
issues. I thank Congressman Salazar for testifying here today
regarding his bill.
We are here today because we are committed to preventing
helicopter EMS accidents. I look forward to the witnesses'
testimony on current and future actions industry and government
can take to improve helicopter EMS safety. Safety is and must
always be priority one.
This brings me to the second issue that we will explore at
this hearing today, State regulation of helicopter EMS.
Currently, States have the authority to regulate medical care
inside the aircraft, including establishing minimum
requirements for medical equipment, as well as training and
licensing requirements of the medical crew. My home State of
Illinois requires EMS helicopters to be equipped with a cardiac
monitor and an extra battery, a defibrillator that is
adjustable to all age groups, an external pacemaker, two
sources of oxygen, in addition to other medical equipment.
However, the Airline Deregulation Act of 1978 stipulates
that these States do not have the authority to regulate rates,
routes, or services of air carriers.
Several States have tried to adopt regulations pertaining
to helicopter EMS that control items other than medical care,
such as the Certificate of Need program, rate setting, and
limitation on geographic service areas. Courts and the
Department of Transportation have found that many of these
State regulations were essentially economic regulations of air
carriers that were preempted by ADA, or the Airline
Deregulation Act.
For example, a Federal court in North Carolina recently
found that the State regulations establishing a Certificate of
Need program limiting the number of helicopter EMS operators in
the State was preempted by ADA. Accordingly, some are calling
for clarification of the ADA to allow States to have a greater
hand in regulating aspects of helicopter EMS that may be
considered to be preempted by the ADA. They argue that States
regulate ambulances on the ground; therefore, they should be
able to regulate ambulances in the air.
However, the issue is not that simple. Air medical
transport is an interstate operation. I have concerns about
allowing each State to separately regulate helicopter EMS
services.
In 2007, the National Academy of Sciences issued a report
stating that there is a need to address inefficiencies and
problems with the entire emergency medical services, and by
trying to tackle the issue of State regulation of helicopter
EMS, we may be missing out on ``the big picture issues'' of the
EMS system as a whole.
Congressman Altmire and Congresswoman Miller introduced
legislation addressing State regulation of medical helicopters.
I thank them for bringing these issues before the Subcommittee.
The provisions in this legislation are extremely complex, and I
hope to have a good discussion of these issues.
Before I recognize Mr. Petri for his opening statement, I
ask unanimous consent to allow two weeks for all Members to
revise and extend their remarks, and to permit the submission
of additional statements and materials by witnesses and
Members. Without objection, so ordered.
At this time, the Ranking Member of the Full Committee, Mr.
Mica is here, and I understand has an opening statement or a
comment.
Mr. Mica, you are recognized.
Mr. Mica. Well, thank you for recognizing me, and also
thank you for convening this hearing. I also want to say that I
appreciated your opening remarks. Very well said. I think you
have covered the issues and challenges that we face on this
issue.
I requested a hearing back in September, and I think Mr.
Petri did in the earlier part of this year. From time to time,
as a former Chair of the Aviation Subcommittee, I think there
are issues that reach a certain level that we can't ignore them
and we must address them, and I am pleased that this hearing is
going to address what I considered last year to be an
unacceptable level of fatalities with medical assistance
helicopters. Their intention is great and they save thousands
of lives every year, but sometimes we have experienced the
heartbreak, in fact, I have known folks that have unfortunately
lost individuals in that type of accident trying to save their
life, but their life was lost in the course of that rescue
effort.
I don't have answers, Mr. Chairman or Mr. Ranking Member,
but I think that we can take from this hearing. We have several
Members with some well-intended legislative proposals, and I
think we need to very seriously look at those.
We don't want the cure, though, to be worse than the
problem that we are experiencing, and we do have, as you
pointed out in your opening statement, multi-jurisdictional
layers of responsibility; there are State issues here, Federal,
medical. Do we regulate by law? Should FAA adopt additional
measures?
Most of the accidents have occurred either in bad weather
or at night, I think our staff reviewed, and that is of
particular concern to me. I am not sure if we have technologies
to deal with all of this, because most of these helicopters fly
at very low levels, and they are going into a disaster scene to
begin with, usually in bad weather conditions or at night.
So I do think that this hearing will be most helpful in
hearing from experts, and hopefully they can give us some
concrete solutions or some steps that we can take. So I look
forward to working with you. Thank you for conducting this
hearing. I won't be able to stay for the whole thing. As you
know, Mr. Oberstar and I are committed on a couple of important
issues today. I will follow up very carefully with you and
support whatever you and Mr. Petri can come up with as positive
solutions. Thank you. I yield back.
Mr. Costello. The Chair thanks the Ranking Member and now
recognizes Mr. Altmire.
Mr. Altmire. Thank you, Mr. Chairman. I want to commend you
for holding this hearing and the two important issues
surrounding helicopter medical services, aviation safety and
patient safety. When we see the crashes on the front page of
the newspapers, we are horrified and we know that we must act
to address aviation safety. But so too must we address patient
safety. The stories aren't hitting the front page of the
newspapers in same dramatic way, but they are numerous and they
are real. Patients are being harmed and put at risk everyday by
a broken air medical system that is supposed to protect them.
There are numerous stories illustrating patient safety
problems in our air medical system. These stories include
infants arriving at hospitals code blue with temperatures 10
degrees below normal because the helicopter was not heated. In
one case, a premature infant was also improperly intubated and
secured during the flight. Patients have experienced delayed
transports when air medical systems stack the flights and say
they will transport a patient, even though they have to wait
until the helicopter frees up. Patients have died during these
waiting periods, even though a closer helicopter was available
but never called.
Requests to move medical helicopters off hospital helipads
to accommodate other incoming medical helicopters for patient
transports have been refused. There have been instances of
blatant inadequacy in the structure of the aircraft itself, in
one case resulting in a child receiving a second degree burn
and requiring skin grafts because the bed he was riding in was
too close to the heating vent on the helicopter.
Unfortunately, these are not isolated instances. These are
real patients who have been harmed or put at risk in areas
where there is fierce and unregulated competition among medical
helicopters. When there is economic pressure to fly as much as
possible and as cheaply as possible, undue risks are inevitably
taken.
States must have the right to regulate competition to
ensure that business interests do not trump patient safety.
H.R. 978, which Representative Miller has joined me in
cosponsoring, would create a protected sphere in which States
can regulate helicopter medical services notwithstanding the
Airline Deregulation Act. This bill is endorsed by 55 air
medical programs, 7 Part 135 operators, and 11 health
organizations, including the National World Health Association
and the National EMS Physicians Association, and I am pleased
to announce that just today, in the Senate, companion
legislation was introduced by Senators McCaskill and Snowe. S.
848 incorporates some of the helpful suggestions to this
Committee following recommendations by the FAA and the DOT.
While the FAA regulates the aviation aspects of air
ambulances, I believe States must be able to fully regulate the
medical part, aboard the helicopter and beyond. Our bill would
allow States to regulate in the following ways: by ensuring
quality care aboard the helicopter with the medically necessary
equipment, aircraft attributes and qualified personnel safety
for severely sick and injured patients; coordinate HMS services
as part of the State EMS system so patients are transported to
the right place at the right time; determine how helicopters
are needed, establishing base locations and designating service
areas to back up protocols to better prevent air medical
programs from call-jumping, stacking flights, or fighting for
patient transports; requiring programs to be available 24/7 and
preventing them from performing wallet biopsies on patients
needing emergency transport.
These tools would be available for States to better
regulate helicopter medical services and protect their
citizens. This bill does not impede access to rural and
underserved areas; it provides States the tools to improve
access to underserved areas by enabling them to better ensure
service coverage. It also allows States to regulate over-
saturated markets where regulated competition is producing the
problems I have outlined. It does not affect rates. Rates are
simply not within the protected sphere of State regulation, and
the ADA still prohibits States from regulating rates. It does
not prevent interstate movement of helicopters. The legislation
affects point-to-point transports within the State only. It
does not impede on FAA authority over aviation safety. FAA
flight safety rules supersede State medical regulations.
I have been pleased to be working with the Subcommittee,
the FAA, and the DOT, and other interested parties to identify
clarifications that can be provided to improve this
legislation, and I very much appreciate the input of all these
groups.
As a final note, Mr. Chairman, let me stress that the ADA
preemption provision has generally worked in the aviation
industry for reducing costs and improving services. However, it
is not working in helicopter medical services. Instead, it has
resulted in lowering the standards of care and higher costs for
patients and insurers.
I appreciate the consideration of this Subcommittee and
Chairman Costello in working to address patient safety. We are
all trying to protect the same critically ill patients being
transported by medical helicopters, and I look forward to
continuing working with everyone involved.
Thank you, Mr. Chairman.
Mr. Costello. The Chair thanks the gentleman from
Pennsylvania and thanks him for his leadership on this issue.
In addition to Ranking Member Mica and Petri requesting this
hearing, Mr. Altmire requested the hearing as well, and we
appreciate your leadership and look forward to working with you
on your legislation and trying to come up with a solution that
can address the problem that we are all concerned about.
The Chair now recognizes the Ranking Member of the
Subcommittee, Mr. Petri.
Mr. Petri. Thank you for scheduling this hearing, Mr.
Chairman.
And my colleague, John Salazar, thanks you for your
patience as you listen to all of us give our five minute
remarks. I have a lot of fond memories of visiting the rail
safety and experimental station in your district in Colorado
some years ago.
From December 2007 to October 2008, 35 people lost their
lives in 13 helicopter emergency medical services accidents,
the most ever in an 11-month period. One of these accidents
where the pilot, flight paramedic, and flight physician were
killed occurred last year in my own State, in La Crosse,
Wisconsin.
Any aviation accident is a terrible heartbreaking event. In
helicopter EMS crashes, the professionals who risk their lives
to help others are often among those who are killed.
Mr. Mica and I and Mr. Altmire requested this hearing to
provide the opportunity for those directly involved to share
their expertise and insights on how to address this important,
but complicated, aviation safety issue.
I understand that there is no silver bullet to aviation
safety, and helicopter EMS is no exception. It will take the
focus and effort of Federal regulators and industry
stakeholders to improve the safety of helicopter EMS flights. I
am interested in learning about the ongoing regulatory efforts
at the FAA to address helicopter EMS safety. I am also
interested to hear what technologies made pilots and operators
in their singular mission of safe patient transport.
As we take up possible legislation, we must carefully
consider congressional mandates for helicopter EMS equipment or
operating standards. It is important to thoroughly explore
which technologies make the best sense to improve aviation
safety. But, at the same time, we must give appropriate
attention to the unique operating environment and the recently
updated regulatory structure under which helicopter EMS flights
operate.
H.R. 1201, introduced by Mr. Salazar and Mr. Lungren,
highlights the safety areas, technology, and operating
standards to be explored by this Subcommittee today. We have
witnesses ready to discuss these issues, and I look forward to
hearing our panelists' viewpoints on the proposed legislation.
It is my understanding we will also consider H.R. 978, as
introduced by Mr. Altmire and Mrs. Miller. Their bill seeks to
clarify--and some may argue expand--State authority over air
medical flights. I believe this Committee must carefully
consider the impact H.R. 978 could have on FAA regulatory
oversight of aviation safety. If the helicopter EMS sector of
the aviation industry were to be treated differently in terms
of State versus Federal oversight, a number of issues come to
mind. For instance, would other sectors of the aviation
community, all unique in their own right, feel justified in
demanding their own carve-out from Federal regulations?
Federal oversight of the aviation industry has long ensured
one standard of safety oversight and operational requirements
nationwide. It has also provided a level playing field for
competition. Across the aviation industry, competition has had
a positive effect on safety and prices available to consumers.
The delegation of economic regulatory authority from the
Department of Transportation to the various States, as directed
in H.R. 978, is a fundamental shift in oversight of the air
transport industry. It is the responsibility of this
Subcommittee to understand and consider all potential effects
on aviation safety, competition, and access to helicopter EMS
care for consumers before such a monumental shift is mandated.
Again, I look forward to a lively discussion on the issues
and, in the interest of time, I want to thank the witnesses for
their participation and yield back the balance of my time.
Mr. Costello. The Chair thanks the Ranking Member and now
recognizes the distinguished Chairman of the Full Committee,
Chairman Oberstar.
Mr. Oberstar. Thank you very much, Mr. Chairman, Mr. Petri,
both, for holding this hearing and inquiring into this
extremely important subject matter that frankly has a great
many people deeply concerned.
You have quite a lineup of witnesses today, including our
former Committee colleague, Mr. Salazar. He is still an
emeritus Member of the Committee. We welcome him back, these
refugees who take respite in another Committee.
But you are always on call, I want you to know, Mr.
Salazar.
I have had time to reflect a bit, Mr. Chairman, on the
previous hearing in this Subcommittee on the U.S. Airways
remarkable survival of a bird strike, and after reviewing the
testimony and thinking it through, it seems to me that we ought
to have perhaps not a hearing, but perhaps an in camera, as is
quaintly said in Latin, discussion with NTSB, with the FAA,
with Boeing and Airbus, and discuss the adequacy of testing of
engines with bird strikes.
As I reviewed the testimony, review the literature in the
field, it seemed to me that the entire testing process is
inadequate. One bird 1.2, 1.4, 2.5 pounds, largest used was a 7
pound bird. Nothing of the size of the Canada geese, which are
like--I don't want to offend Canada geese lovers; it is pretty
hard to find any, but they are winged very heavy rats, as my
friends on the docks call them; and they can rise to 20 to 25
pounds. Many of them are inept at flying because they spend so
much time on the ground, those domesticated critters. They
haven't used the central Mississippi flyway in years, nor the
east coast flyway in years. But they do manage to get up to
3,000 feet.
And while FAA and U.S. Airways and Airbus and the engine
manufacturers, CFM, all considered it to be a success that
there was not an uncontained engine failure, it still was a
failure, and I think we need to have them come with some
technical specifications and review with us the adequacy of the
testing, the construction of engines, and not limit this
roundtable discussion. It ought to be inclusive on the
Committee, we don't need to have a public hearing on the
subject, but I think we need to have a very in-depth technical
review. There are only a handful of engine manufacturers--
Snecma, Pratt and Whitney, GE, and Rolls Royce with their Trent
engine series--that power major commercial aircraft.
Perhaps we ought to have them come in and talk with us
about the adequacy of standards on the fan blades, those
titanium fan blades. How they get inspections for very small
imperfections. As little as a millimeter of indentation in the
fan blade is enough to take it out of service and replace it.
But what when it entirely disintegrates and when the pieces get
into the bypass or other portions of the engine? Aircraft
engines are enormously reliable. If you go to the 1940s, the
time between overhaul was 300 hours; you get into the 1950s,
time between overhaul was up to 600 hours; and then with the
DC-9 it got up to 30,000 hours time between overhaul; and now
it is up to 50,000 hours. Wonderful, except it can't withstand
a bird strike. And we are not testing those engines adequately
at a level to protect life.
And then we ought to also have both Boeing and Airbus
report to us on their structural standards for the hull. The
crew made a very good decision to, in effect, create a tail
strike on landing and gently get that aircraft into the ground,
but the hull buckled and water entered the cabin. That is not
very encouraging when you have to face the prospect of putting
on a life vest inside the cabin to float and get yourself out.
There perhaps are some design inadequacies of hull construction
that we also ought to take a look at.
So as you pursue this very important inquiry today, and we
have in the room the Flight Standards Service, we have the
NTSB, we have Dr. Dillingham from GAO, all of whom are familiar
with these subject matters--I put them on notice, at your
direction, we would have a follow-up inquiry on this subject.
Thank you.
Mr. Costello. The Chair thanks you and will advise all
Members that your entire opening statement will be inserted in
the record. We would ask that you give brief comments.
Now, the Chair will recognize the gentlelady from Texas,
Ms. Johnson.
Ms. Johnson. Thank you very much, Mr. Chairman, and thank
you for having this important hearing. It is extremely
important to me, having practices professional nursing for a
number of years. I can speak firsthand on the importance of
rendering emergency care within critical time windows
immediately following a serious accident. And, without
question, the proliferation of helicopter emergency medical
services, or HEMS, has proven to be literally vital, important
lifesaving tool in the preservation of life for countless
accident victims by ensuring that they are able to receive
timely medical attention.
According to the 2005 report by Helicopter Association
International, in 1991, there were 225 helicopters dedicated to
air medical service. Today there are approximately 850 in
service, providing for approximately 81.4 million Americans.
However, as the data before us may suggest, this proliferation
has not come without its share of fatal accidents, many of
which aviation experts indicate could have been prevented.
Over the past year, accidents involving HEMS has increased
significantly relative to previous years, and according to the
data provided by staff, there were 13 HEMS accidents, resulting
in 35 fatalities between December 2007 and October 2008, and
that is the most in any 11-month period in history.
Thank you, Mr. Chairman. I will submit the rest of my
statement to the record.
Mr. Costello. The Chair thanks the gentlelady and now
recognizes the gentleman from Tennessee, Mr. Duncan.
Mr. Duncan. Thank you very much, Mr. Chairman. I don't have
a lengthy formal statement, but I do want to first thank you
and Ranking Member Petri for calling this hearing. I want to
also commend our colleagues, Congressman Salazar and
Congressman Altmire, for their interest in this.
There is great interest in this subject, as I found out,
because I have been contacted by both the University of
Tennessee Hospital in Knoxville and the Vanderbilt University
Hospital in Nashville about this legislation, and I have some
interest in it that several years ago I introduced the Aviation
Medical Assistance Act, and we made that a part of one of our
FAA reauthorizations to increase the medical training for
airline personnel and to create the first Good Samaritan law in
the skies to erase any concerns doctors or nurses or others
might have in rendering assistance during medical emergencies
in planes. So it is along these same lines that we are dealing
with, some of these subjects here today.
I also have come with great interest to welcome back our
former staffer, the new Acting Assistant Secretary, Ms.
Fornarotto. I don't want to put any extra pressure on her, but
I am looking forward to her first testimony before the
Committee.
Thank you, Mr. Chairman.
Mr. Costello. The Chair thanks you and now recognizes the
gentleman from Michigan, Dr. Ehlers. Then we will go to our
first witness, Congressman Salazar.
Mr. Ehlers. Thank you, Mr. Chairman. I will try to be
brief. I am a proud cosponsor of the Miller-Altmire bill, and I
think it is needed.
Michigan has always done pretty well. We have a very
functional EMS system. The State controls it through a
Certificate of Need program. We have coverage over the entire
State, even though much of Michigan is highly rural or even
less than rural, and the system works well.
It is ironic that this hearing came now, but we had our
first accident in a Grand Rapids helicopter this summer.
Ironically, I was up in the air taking a flying lesson at the
time and saw this huge plume of black smoke coming up from the
center of Grand Rapids, so I got on the ground and started
driving back. Fortunately, there were no patients aboard the
helicopter; it crashed while landing at the hospital. The only
other person besides the pilot was an FAA inspector, who was
forcing the pilot to go through all his procedures and somehow
a gust of wind caught them and they caught fire.
Be that as it may, we have a good record in Michigan, and
we have lots of discussions in the newspapers, both letters to
the editors and news analysis, about the accident and so forth,
and recognize no one got killed. They did lose a helicopter,
but the interesting fact that emerged is that the number of
fatalities or injuries of patients was much higher in land-
based ambulances than it was in air ambulances, which indicates
the very good record that we have in Michigan.
So I would just urge that we recognize that some States and
some communities do it right, and let's be careful, as we go
through this, that we not in some way endanger the operations
that are already working well, and try to bring all the others
up to snuff.
There is absolutely no reason to have a surplus of
ambulances, these air ambulances. These are very expensive
machines, very high hourly rate, and that money has to be paid
somehow. I think if we have too many, then you are really
boosting the cost of medical care in a way that is not
necessary.
With that, I yield back. Thank you.
Mr. Costello. The Chair thanks the gentleman.
Now we will go to our first panel, the Honorable John
Salazar, representing the 3rd District of Colorado. As Chairman
Oberstar, Congressman Salazar served on this Subcommittee and
the Full Committee before he moved on to another Committee, but
we still consider him family and look forward to hearing his
testimony.
You are recognized, John.
STATEMENT OF HON. JOHN T. SALAZAR, A REPRESENTATIVE IN CONGRESS
FROM THE STATE OF COLORADO
Mr. Salazar. Thank you, Mr. Chairman. Chairman Costello,
Ranking Member Petri, and Members of the Committee, it is an
honor to be back to my old Subcommittee, one of the greatest
Subcommittees, I think, in Congress. I want to thank you for
inviting me today to testify on the topic of air medical
service, and specifically on the bill that we have introduced,
H.R. 1201, the Air Medical Safety Act. I also want to commend
the Chairman, Chairman Costello, for your leadership on this
issue, and Ranking Member Petri, as well as other Members of
the Committee.
I consider H.R. 1201 to be a starting point on this
critical safety issue. Since its introduction, my staff,
Cathleen Breslin and members of this Committee's staff as well,
have worked with the FAA, with the NTSB, with the industry and
a number of advocacy groups to ensure that this legislation is
fair, effective, and meaningful.
We have already made a number of changes, most of them
technical, but important nonetheless. Among them, changing the
word pilot to certificate holder and requiring a rulemaking on
devices that perform the function of recording voice
communications and flight data information. We are also adding
terrain and obstacle avoidance systems to the bill, a key
component to enhance EMS flight safety.
Before I go further, I would like to recognize Stacey
Friedman, who will be testifying later. Stacey's sister, Erin
Reed, was a flight nurse who died in September of 2005 when her
helicopter lost control in inclement weather conditions after
delivering a patient to a nearby hospital.
I would also like to recognize Congressman Dan Lungren, who
is the cosponsor of this bill with me.
I think this is a very important piece of legislation. It
is bipartisan and I can assure you that human safety is not a
partisan issue. Our bill increases the safety of crew and
passengers on aircraft providing emergency medical services,
EMS.
We have a very important person on this Committee - Jimmy
Miller, Director of Facilities and Travel, whose life was saved
because of EMS. A wonderful, great service to this Committee.
We appreciate that, Jimmy, and I appreciate working with you
over the last several years.
Our bill increases the safety of crew and passengers on
aircraft. Colorado has seen three fatal crashes of EMS flights
since 2000, and all of those have occurred in my district. The
most recent one was in Alamosa, which is 30 miles away from my
home, in October of 2007. The other two crashes were in 2005,
one based out of Steamboat Springs, Colorado and the other one
near Mancos, Colorado.
H.R. 1201 includes recommendations that the National
Transportation Safety Board made to the FAA in response to
several air medical crashes to help improve safety. One of the
issues on their list was the impact of Part 91 of the FAA code.
This was brought to my attention by St. Mary's Care Flight
operating out of St. Mary's Hospital and Medical Center in
Grand Junction, Colorado.
A great majority of air medical crashes over the past five
to seven years have been conducted under FAA Part 91
regulations. As many of you know, Part 91 allows EMS crews to
fly in conditions which are more dangerous than what is
permitted when a patient or an organ is onboard. Specifically,
it allows for much less stringent weather minimums and does not
restrict pilot duty time, compared to Part 135 of the same
code. The lives of our pilots and air medical crews should be
protected by the same weather minimums and pilot duty time
requirements that these patients are afforded during their leg
of transport.
So this bill will eliminate the Part 91 regulations for
certain flights and direct the FAA to study and implement
several other proposals to increase safety conditions for
medical flights. I do credit the FAA for some recent
advancements in this area, but I still believe that much more
needs to be done, and in a timely manner.
In closing, I would like to recognize the efforts of the
many families who have responded to their losses with
determination to help others. By increasing safety conditions
for medical flights, we will not only honor the remarkable
sacrifices of those who gave their lives while trying to help
others, but in their honor we will also prevent similar
tragedies from occurring in the future.
I want to thank this Committee. I want to thank the
Chairman and Mr. Petri once again for giving me the opportunity
to speak with you today.
Mr. Costello. The Chair thanks you. It has been the
tradition of this Committee not to ask the Member to wait to
answer questions. We realize that you have a busy schedule. If
Members have questions, we will submit them in writing. Again,
we thank you. We thank you for your legislation, and we look
forward to working with you to try and come up with legislation
that is in the best interest and accomplishes what we are
attempting to do here with this hearing, and what you and Mr.
Altmire and others are attempting to do with your legislation.
Thank you.
Mr. Salazar. I want to thank you, Mr. Chairman.
Mr. Costello. The Chair would ask the first panel of
witnesses to come forward. I will introduce them as they are
taking their seats.
The Honorable Christa Fornarotto, Acting Assistant
Secretary of Aviation and International Affairs, with the U.S.
Department of Transportation; Mr. John Allen, the Director of
Flight Standards Service, Federal Aviation Administration; the
Honorable Robert Sumwalt, III, Board Member with the National
Transportation Safety Board; Dr. Gerald Dillingham, the
Director of Physical Infrastructure Issues, U.S. Government
Accountability Office.
We would ask all of our witnesses to take their seats. In
the interest of full disclosure, let me say that Ms. Fornarotto
used to be my legislative director and was a staff member of
this Subcommittee for a number of years. Mr. Petri and I were
just talking. He suggested we may want to swear you in, but I
think we are going to not do that today.
[Laughter.]
Mr. Costello. Let me welcome all of you here today on this
important topic. First, let me say that your full statement
will be entered into the record, and we would ask that you
summarize your testimony under the five minute rule.
The Chair now recognizes Ms. Fornarotto.
TESTIMONY OF THE HONORABLE CHRISTA FORNAROTTO, ACTING ASSISTANT
SECRETARY FOR AVIATION AND INTERNATIONAL AFFAIRS, U.S.
DEPARTMENT OF TRANSPORTATION; JOHN ALLEN, DIRECTOR, FLIGHT
STANDARDS SERVICE, FEDERAL AVIATION ADMINISTRATION; THE
HONORABLE ROBERT L. SUMWALT, III, BOARD MEMBER, NATIONAL
TRANSPORTATION SAFETY BOARD; AND DR. GERALD DILLINGHAM,
DIRECTOR, PHYSICAL INFRASTRUCTURE ISSUES, U.S. GOVERNMENT
ACCOUNTABILITY OFFICE
Ms. Fornarotto. Mr. Chairman, Mr. Petri, Members of the
Subcommittee, thank you for inviting me to this hearing. The
Department of Transportation takes air ambulance services
issues very seriously, and we appreciate the opportunity to
testify here today.
H.R. 978, the Helicopter Medical Services Patient Safety
Protection and Coordination Act, contains several provisions
that seek to provide States with additional authority to
regulate helicopter air ambulances. Under current law, air
ambulances are air carriers subject to the Airline Deregulation
Act of 1978. The ADA ended the government's economic control
over airfares and services, and, instead, relies on competitive
market forces. As such, States are prohibited from enforcing
regulations related to air carrier prices, routes, and
services.
That said, the ADA has no bearing on a State's ability to
regulate the medical aspects of air ambulances, including
patient medical care. It is has long been the Department's view
that the provision of medical services is not aviation
services, and, thus, not preempted by the ADA.
The Department of Transportation has long supported the
authority of States to issue FAA compliant regulations on
patient care that would affect air ambulance operations. We
recognize the interest States have in ensuring that medical
professionals on board air ambulances are properly qualified
and that air ambulances arrive properly equipped with the
medical and communications equipment necessary to care for
patients and communicate with emergency medical services
personnel on the ground.
Although State regulations that would affect air ambulances
must always be compliant with FAA requirements, we believe that
there is a wide range of medically related interests that
States can, and currently do, regulate without encroaching on
the Department of Transportation's economic authority under the
ADA.
We have strong concerns, however, that carving out
statutory exemptions to the ADA for purposes of allowing States
to regulate economic issues involving one segment of the
aviation industry will lead to many of the same problems that
Congress sought to avoid when it passed the ADA's preemption
provision over 30 years ago. More specifically, we are
concerned that the legislation, one, could serve to limit
market entry and could ultimately have a negative effect on the
available services, given market access in aviation services
generally has been instrumental in promoting a safe, efficient,
and responsive industry; two, potentially would create
conflicting State rules that may prevent patient transport
across State lines; and, three, may create a slippery slope for
the federally regulated aviation industry should Congress set a
precedent in the area of air ambulances.
I also note that the bill would distinguish EMS helicopters
from EMS fixed wing air carriers. While the Department has
concerns over the legislation generally, we see no appropriate
basis for making this distinction.
Given these concerns, we ask that before the Committee
legislates in the area of economic regulation, that it consider
carefully whether the troubling stories we have read about are
relatively isolated incidents or indicative of a larger
systemic problem. For example, among those testifying before
you today are two groups representing participants in the air
ambulance industry. At the Department, we have met with these
organizations, and what concerns us most is the lack of
agreement and actual hard data not only on the nature of the
problems with the existing system, but on whether systemic
problems exist.
We recognize that we have had several air ambulance crashes
in 2008, and these tragedies shine an important spotlight on
safety within this industry. Some have criticized the
industry's business structure, but can point to no study or
recurring evidence that competition has compromised air safety
and medical care.
In closing, Mr. Chairman, we look forward to working with
you, Congressman Altmire, other Members of this Committee, and
interested stakeholders to address this important aviation
issue. Thank you for the opportunity to testify today, and I
would be happy to answer any questions or comments you may
have.
Mr. Costello. The Chair thanks you and compliments you on
your first visit and testimony before this Subcommittee.
The Chair now recognizes Mr. Allen.
Mr. Allen. Chairman Costello, Ranking Member Petri, Members
of the Subcommittee, thank you very much for inviting me here
today to discuss the safety oversight of helicopter medical
emergency services, also known as HEMS.
HEMS operations are a critical aviation service provided to
the medical community. The medical treatment aspect is
obviously an essential part of a HEMS operation. However, the
FAA's mission is to assure the safety of the air transportation
portion of the operation. The best medical treatment in the
world won't make a difference if the patient and crew can't be
transported safely.
The FAA is taking steps to improve the safety in this
evolving industry. As always, our goal is to have a zero
percent accident rate. Unfortunately, there has been a spike in
the number of fatal HEMS accidents in 2008. From 2002 to 2007,
there were 26 fatal HEMS accidents, an average of 4.3 accidents
per year. In 2008 alone there were 8 fatal HEMS accidents.
These 34 accidents have resulted in 89 fatalities, 71 of whom
were crew members.
One of the things that the FAA has identified that can
improve the safety of HEMS flight is to build a strong safety
culture in the industry. These operations take place in very
demanding environments. The pilot's judgment and risk
assessment is critical in deciding whether an air ambulance
flight request should be accepted. When weather or other
conditions put flight delay or cancellations on the table, the
pilot must have the fortitude to make the call of go or no go.
The FAA believes that the operator must create a safety culture
and environment that promotes and supports the safety decisions
and good judgment exercised by the pilot.
The FAA has taken several other steps to immediately
improve HEMS safety while working on a formal rulemaking. In
2004, we engaged the industry in several voluntary compliance
measures. In this way, we effect immediate change and see
safety benefits right away. Our changes have included raising
the weather minima by operation specification, which we also
refer to as OPSPEC. These higher weather minima provide better
visibility conditions for safe flight.
We have also issued guidance on establishing operational
control or dispatch systems and risk assessment programs. In
December 2008, we issued a technical standard for helicopter
terrain awareness and warning systems, also referred to as
HTAWS.
We are pleased that the HEMS industry has been very
responsive in voluntarily adopting these measures. In January
2009, the FAA conducted a survey of all HEMS operators. We
wanted to find out how many have actually implemented FAA-
recommended best practices. We found the response to be
overwhelming. Well over 80 percent of the operators have
established risk assessment programs and operational control
centers, almost 90 percent are using radar altimeters, while
just over 40 percent have voluntarily equipped some or all of
their fleets with HTAWS. We expect this last percentage to rise
now that the HTAWS technical standards order has been
published.
We recognize that relying on voluntary compliance alone is
not enough to assure safe flight operations, so the FAA has
initiated a formal rulemaking project that will address many of
the HEMS initiatives and best practices.
We appreciate both Congressman Salazar's and Congressman
Altmire's efforts in the proposed bills to continue to raise
the bar on HEMS safety; however, the current regulations, the
industry's voluntary safety efforts, and our rulemaking effort
already address the safety issues in H.R. 1201.
The FAA also appreciates that the intent of H.R. 978 is not
to infringe upon the FAA's safety authority or for civil
aviation. And, in order to ensure that there are no unintended
consequences of either bill that might adversely affect HEMS
safety, the FAA stands ready to work with this Committee to
address any safety concerns.
Mr. Chairman, Congressman Petri, Members of the
Subcommittee, this concludes my prepared remarks. I am happy to
answer any questions you may have.
Mr. Costello. The Chair thanks you and now recognizes Mr.
Sumwalt.
Mr. Sumwalt. Good morning, Chairman Costello, Ranking
Member Petri, and Members of the Subcommittee. Thank you for
the opportunity to present testimony on behalf of the National
Transportation Safety Board.
I would like to give you a short summary of the Safety
Board's activities regarding the safety of helicopter EMS
operations, or HEMS.
The HEMS industry provides an extremely important service
by transporting seriously ill patients and donor organs to
emergency care facilities. Indeed, they are credited with
saving countless lives each year. That said, the recent
accident record is alarming, and it is unacceptable. In the
past six years, there have been 84 HEMS accidents resulting in
77 fatalities and last year alone was the most deadly year on
record for medical helicopters.
The Safety Board has had a longstanding interest in EMS
aviation. For example, in 1988, the Board conducted a safety
study of commercial EMS helicopter operations. That study
evaluated 59 EMS helicopter accidents and resulted in the
Safety Board issuing 19 safety recommendations.
Prompted by a recent rise in EMS accidents, in January of
2006, the Safety Board adopted a special investigation report
EMS operations. That special investigation analyzed 55 EMS
accidents that occurred in a three-year period, and claimed 54
lives. As a result of that special investigation, the Safety
Board issued four recommendations to the FAA to improve safety
of these operations. Of significance, the Safety Board
determined that 29 of the 55 accidents could have been
prevented if the corrective actions in the report had been
implemented.
These safety recommendations called on the FAA to require
all EMS flights, even those without passengers onboard, to be
conducted in accordance with FAR Part 135 on demand charter
regulations; to develop and implement flight risk evaluation
programs; to require formalized flight dispatch and flight
following programs, including up-to-date weather information;
and install terrain awareness and warning systems, or TAWS, on
aircraft.
These recommendations were added to the Safety Board's Most
Wanted List of Transportation Safety Improvements in October of
2008, and the decision to place these recommendations on the
Safety Board's Most Wanted List was prompted by two primary
reasons: one, the FAA's lack of timely action on the
recommendations and, two, the appalling number of helicopter
EMS accidents. Currently, three of the four recommendations on
this list are classified by the Board as ``Open, Unacceptable
Response.''
The Safety Board is concerned that these types of accidents
will continue if a concerted effort is not made to improve the
safety of emergency medical flights.
In February of this year, the Safety Board held a four-day
public hearing on HEMS, making it one of the longest NTSB
public hearings on record, and I was privileged and honored to
serve as chairman of the Board of Inquiry for that public
hearing. The hearing took a comprehensive look at the HEMS
industry. We looked at business models, the growth in the
industry, and competition; we examined flight operations
procedures, including flight planning, weather minimums, and
pre-flight risk assessment; we discussed safety enhancing
technologies such as terrain awareness and warning systems
(TAWS) and night vision imaging system (NVIS); training,
including the use of flight simulators, was discussed; and we
probed the corporate and government oversight of the HEMS
industry.
Possible courses of action that could result from this
hearing are numerous, including an updated safety study on EMS
operations and additional safety recommendations. The NTSB
staff are currently examining the information obtained from the
public hearing, which totals over 3,000 pages of documents.
Whatever we do, the Safety Board's motivation is simple: to
find innovative ways to improve helicopter EMS safety.
I am very pleased to hear this morning that the FAA has
announced a rulemaking initiative, and the Safety Board looks
forward to following the progress of this rulemaking effort.
Mr. Chairman, this concludes my testimony, and I would be
glad to answer questions at the appropriate time.
Mr. Costello. The Chair thanks you and now recognizes Dr.
Dillingham.
Mr. Dillingham. Good morning, Chairman Costello, Mr. Petri,
Members of the Subcommittee.
Thanks to the FAA, the wider aviation community, and
congressional oversight, U.S. aviation has one of the safest
records in the world. However, there are segments of the
aviation community that have not achieved the same high level
of safety, and their records remain a significant concern.
In line with both Mr. Sumwalt's testimony and the consensus
of opinion from the NTSB's February 2009 conference, as well as
the statements by Mr. Mica this morning, the industry's recent
accident record is simply unacceptable. Between 1998 and 2008,
there were roughly 146 air ambulance accidents in the United
States, 48 of which resulted in the deaths of over 125 people.
This means that the industry averaged 13 accidents and 12
fatalities per year during that time period.
In 2008, the number of fatalities increased sharply to 29.
Because the industry grew substantially during that period, and
because FAA does not systematically collect and analyze data on
air ambulance operations, we can't really be sure what these
numbers mean in terms of the industry's accident rate.
Nevertheless, the overall number of accidents and the spike in
the number of fatal accidents in 2008 are causes for concern.
Our analysis of the data on air ambulance accidents showed
that pilot error was the probable cause of 70 percent of the
accidents that occurred during the last decade. Additionally,
flight environmental factors, such as nighttime flying, adverse
weather, and flight into terrain contributed to 54 percent of
these accidents. In some locales, competition has increased
with a growth in the number of standalone air ambulance service
providers and changes in the Medicare reimbursement rules.
Some experts say that competition has led to potentially
unsafe practices, such as helicopter shopping. NTSB's aviation
accident database does indicate that crashes have occurred
after pilots have taken risky action, such as accepting flights
after another pilot refused to fly because of bad weather.
In response to the increased number of accidents, NTSB made
four significant recommendations in 2006, and FAA and the
industry have also implemented a wide range of initiatives to
improve safety. As Mr. Sumwalt testified, despite these
initiatives, 2008 was the deadliest year on record for the air
ambulance industry.
Additional efforts are clearly warranted. The question is
where do we need to go from here. We have identified several
strategies with the potential to improve air ambulance safety.
First, FAA and the industry must sustain their current focus on
safety improvements. The pattern of events that we are seeing
now is a pattern that we have seen before. In the mid-1980s,
after a significant increase in the number of air ambulance
accidents, subsequent media and congressional attention, NTSB
recommendations and FAA actions, the number of air ambulance
accidents declined. But as time passed and attention waned, the
number of accidents started to increase, peaking in 2003. We
found a similar pattern in our work on runway incursions for
this Subcommittee.
FAA has taken a positive step towards sustaining its focus
on safety by announcing the start of a rulemaking that will
address NTSB's 2006 recommendations. It is important to note
that sustaining current efforts is critical, because it may be
many years before any new regulations are completed and
implemented by FAA.
A second strategy is for FAA to obtain complete and
accurate data on air ambulance operations. FAA needs such data
to better understand the industry's safety record and determine
whether its own efforts to improve air ambulance safety are
accurately targeted and sufficient.
A third strategy would involve FAA encouraging the
transformation of the air ambulance industry so that operators
would establish a corporate culture based on safety and adopt
tools, such as safety management systems.
A final strategy would use empirical analysis to address
the risk profile of the industry and to help resolve national
issues, such as the role of States in overseeing ambulance
services, the impact of Medicare reimbursement on usage, and
the appropriate use of air ambulance services.
Mr. Chairman, that concludes my statement. Thank you.
Mr. Costello. Dr. Dillingham, thank you.
Mr. Allen, you heard Mr. Sumwalt's testimony, and I will
read it back to you, a part of a statement that he has made in
his testimony. He says the 2006 special investigation resulted
in the Safety Board issuing four recommendations to the FAA to
improve the safety of these operations. Of significance, the
Board determined that 29, 29 of the 55 reviewed accidents could
have been prevented if the corrective action recommended in the
report had been implemented.
Do you agree with that statement?
Mr. Allen. Well, sir, it is a hypothetical situation as to
whether those accidents would have actually been prevented if
those had been implemented. It is understandable that those, if
implemented, would raise the safety bar, and, obviously, we
have been working very, very hard with the industry to
voluntarily comply with many of the NTSB safety
recommendations. It is a question as to how many accidents we
also prevented with the voluntary application of those
initiatives, and we think that there has been a great benefit
to safety with those voluntary applications.
But to understand whether some would have actually been
prevented, there are also other certificate holders out there
who are very fastidious in their application of the regulations
and of many safety initiatives, that have never had an
accident. So I do think, obviously, sir, that the industry is
not wrong and that they would have definitely helped the
prevention of an accident, but I can't say unequivocally that
they would have actually prevented any one of those actual
accidents.
Mr. Costello. I wonder if you might follow up on the
statement that you made, Mr. Sumwalt, that the 29 of the 55
reviewed accidents could have been prevented.
Mr. Sumwalt. That is right, Mr. Chairman. In the special
investigation report, we looked at what intervention measures
hypothetically could have prevented those accidents. For
example, if we saw a controlled flight into terrain (CFIT)
accident, we would say what could have prevented that, and the
answer to that would be the application of a terrain awareness
and warning system, or TAWS. So, therefore, when we saw the 16
or so see-fit accidents in the report, we would say, well, the
TAWS could have prevented those. We did that for each of the
intervention strategies that we had outlined.
Mr. Costello. Dr. Dillingham, you heard Mr. Allen refer to
voluntary compliance. Is that good enough, relying on voluntary
compliance by the industry? Is that adequate or should the FAA
be taking a different approach?
Mr. Dillingham. Mr. Chairman, we think that the voluntary
compliance was a first step, but it clearly is not enough. I
mean, voluntary compliance is--and we agree with the FAA in the
sense that it is easier, quicker to develop voluntary kinds of
compliance while, in the meantime, working on regulatory
issues, such as FAA has just announced that they are in fact
developing rules.
The other point that we want to make is that FAA indicates
that they have checked with the industry in terms of the extent
to which they are actually complying with these voluntary
rules. We have some concerns about how valid that information
is that they are getting, because to the extent that it is
based on data that are collected from less than half the
industry, we don't put too much credit in the validity of that
information.
Mr. Costello. Before I go to other Members to ask
questions, let me just ask you to summarize very quickly what
is it that the FAA needs to do to address this problem. Dr.
Dillingham.
Mr. Dillingham. I think the first thing they need to do is
sustain the actions that they are doing now until the
regulations are enforced. I think they need to collect the
information so that they can monitor the effect of what they
are doing, and they need to further push the use of
technologies such as the TAWS that Mr. Sumwalt mentioned.
Mr. Costello. Mr. Sumwalt, from your perspective, from the
NTSB's, what should the FAA be doing?
Mr. Sumwalt. From our perspective, Mr. Chairman, we would
like to see the FAA implement the rulemaking on the four
recommendations that we have issued. We understand from this
morning that some regulatory action is beginning, but we, of
course, would like to see that rulemaking completed.
Mr. Costello. We all recognize how long rulemaking takes.
It takes a significant time. But I will come back; I have some
other questions and comments.
The Chair now recognizes the Ranking Member of the
Subcommittee, Mr. Petri.
Mr. Petri. Thank you very much, Mr. Chairman. I have
several questions for Ms. Fornarotto and Mr. Allen, who
submitted a joint statement, and we will leave it up to you to
either both respond or whoever would like to respond.
There seems to be, in some of the statements that were
submitted, some confusion as to exactly what authority States
have to regulate medical portions of emergency medical services
flights. Could you clarify what the agency's position is as to
where the line is between what is within States' authority to
regulate and what would be preempted by the Airline
Deregulation Act?
Ms. Fornarotto. Sure. As I said in my opening statement, we
make a strong distinction at the Department between aviation
services and medical services, and we do believe that, under
ADA, we reserve the right to regulate on aviation services, but
States have the right to regulate on medical services. That is
the distinction that we make.
Mr. Petri. But sometimes it requires a modification of the
aircraft to put in a medical device or sometimes there are
questions--I know we had met with some people that were talking
about temperatures in the craft and equipment to achieve that
temperature, and whether you can mandate the temperature or
just mandate the equipment. It is not as automatic a line when
you actually come down to apply it, it does require some give
and take and negotiation, or at least some clarification so
that States don't end up with requirements to comply with which
a plane couldn't necessarily go to another State.
Mr. Allen. Yes, sir. The interfaces, as I call it, between
the medical community and the aviation community are a very key
piece to understanding this whole safety equation. But when it
comes to aviation safety, we affirm that we have responsibility
and authority to have the last call and to have the definitive
statement on what is correct and not correct. That is why we
have been working very closely with Congressman Altmire's
staff, to make sure that there isn't any overlap there and that
there is a clear distinction that the States can have free rein
on regulating their health portion of the operation, but when
it comes to aviation safety, the Federal Aviation
Administration have the authority and responsibility of safety
oversight.
Many of these HEMS operators are interstate versus
intrastate, so, therefore, it is important that we have the
purview of safety oversight for them.
Mr. Petri. Now, you indicated that there is a lack of
agreement not only on the nature of the problem with the
existing helicopter emergency medical system, but whether any
serious problem exists at all with regard to issues surrounding
H.R. 978. Could you elaborate on that? Are you sure the medical
air transportation system is broken, as some have claimed?
Would there be a need for a study in this area, and would you
support such a study?
Ms. Fornarotto. We would. We do believe that clarification
needs to be made. You are going to hear today, we have heard it
at the agency, that there are varying stories on what is going
on in the field, and in order to get clarification on that, in
order to get a better understanding of what is going on so as
to get to the bottom of these issues, we do believe that a
comprehensive study would be very helpful in sorting out what
is going on. So before we actually propose a solution, let's
actually figure out what the problem is first.
Mr. Petri. One final question. I suppose it is obvious, but
maybe you could state how are helicopters different from
ambulances in the air. Why should they be treated differently
from ground ambulance services by the regulators?
Ms. Fornarotto. From an economic side, we look at it in
terms of interstate operations. These operators, they file for
interstate operation certification, and the ADA was very
specific in making sure that air carrier operations were
allowed to fly interstate, and that is where we come at it,
from the interstate perspective.
Mr. Allen. And, sir, obviously from the safety perspective,
it is a very difficult environment to operate in. Low weather
situations sometimes, obstructions on landing zones. You have
the fusion of human factors and technology and environmental
conditions that create quite a safety challenge. So, therefore,
we have--and I don't have any responsibility over the ground
ambulance infrastructure, but over the aviation side we have to
put forth a lot of safety initiatives to adequately ensure that
the safety is at the highest level of this very complex
environment.
Mr. Petri. Thank you. Just one real quick add-on. This is a
unique aviation area, but there are other unique aviation
areas, people providing specialized services of one kind or
another. How real is the concern that if there is a kind of a
carve out or greater State authority in this area, that that
will create problems in other aviation areas? Do you have any
view on that or do you think it is unique enough that, if we
get into this and restrict your authority and enlarge the
States' authority, that that will be the end of the matter?
Ms. Fornarotto. Right now, with the ADA, there are no carve
outs. By going down this road, you are setting up to produce
one carve out, and it is unclear to us if other unique
operations, you know, unique, however you define that, would
also seek a carve out from Congress on that. You know, another
example of an air taxi would be scenic tours that fly around
like at the Grand Canyon or in other places. They are a unique
set of operations and they have high startup costs and other
things about which you can make similar arguments, and we are
very concerned about heading down this road and creating a
slippery slope effect.
Mr. Costello. The Chair recognizes the gentleman from
Pennsylvania, Mr. Altmire.
Mr. Altmire. Thank you, Chairman Costello. I want to ask a
couple of questions for Ms. Fornarotto.
Thank you for being here. And I do appreciate the
assistance that everyone involved has given to our office in
helping to work through some of these issues on which we
clearly differ on some, but we are working through it.
I have the same general question in response to your
testimony. You indicated that the Department of Transportation
says that States should not regulate the economics involved,
and ADA exempts States, but I want to know what is the role of
the Department of Transportation in actually doing that
regulation? Because if it is not being done at the ADA, has the
DOT issued regulations? Is there something that has been
formally done?
Ms. Fornarotto. So Congress passes a law and then one of
the roles of the agency is to enforce the laws, the statutes,
and we do do regulations based on that. And one of the things
we do--and I know that you have seen these--is we do guidance
letters, and if a State comes to us with issues or concerns and
they seek guidance on something specific, we will lay out from
our perspective what guidance we can provide.
Mr. Altmire. I appreciate that. You have also indicated
that the Department of Transportation has said that States can
regulate staffing of medical personnel, medical equipment,
sanitation issues. But the DOT has also said, in a letter
specifically to Hawaii, that criteria related to quality,
availability, accessibility, and acceptability are specifically
preempted. So my question is how can a State assure that the
accountability of the EMS system is in place if it can't
regulate these specific aspects of helicopter medical services?
Ms. Fornarotto. One of the things we are seeing as we go
forward with this and on issues being raised is that each
instance is very unique, and a lot of these are done on a case-
by-case basis. That is why we encourage States to contact DOT
in order to get further guidance, so we can work with them, we
can talk to them about their issues and be partners in going
forward.
Mr. Altmire. So is it your view that States should be able
to oversee only the medical care and equipment provided inside
the helicopter, or should they, instead, be able to oversee the
provision of HMS services, which would include coordination,
location, and availability of services as well?
Ms. Fornarotto. Each is done on a case-by-case basis, and I
want to refrain from trying to say this does fall under the ADA
or this does not fall under the ADA. Everything is very case
specific and we do have to look at the totality of whatever a
State is proposing before we do make a determination.
Mr. Altmire. Thank you. One last question. In your opinion,
should medical helicopter providers be required to pick up all
patients from scenes, even if they are uninsured? And do you
see a legitimate public interest in such things as requiring
24/7 availability of HMS providers? And I ask because since
both of these have been found to be preempted by DOT and DOT
isn't requiring them, then how else can we ensure that patients
receive air medical transport when they need it as part of the
EMS system if States can't set these requirements specifically?
Ms. Fornarotto. So currently under the ADA, things like 24/
7, which you raised, geographic restrictions, things like that,
the ADA preempts. A State can, if they so choose, contract out
those services. If they truly believe that 24/7 is critical, if
serving a specific geographic area is critical, a State can
contract that out.
You are raising a very important question here, and that is
there a unique situation with the air ambulance services, and
from DOT's perspective we are saying let's study this further.
Let's get some more information. Let's see what is going on
before we actually legislate on this, carve-out could have
unintended consequences down the road.
Mr. Altmire. Thank you.
One very quick point for Mr. Allen. I just want to say
publicly how much I appreciate FAA's thoughtful comments on how
we can improve H.R. 978 to ensure one system is safely governed
exclusively by FAA while still ensuring that States can
regulate patient safety and coordination. I am in agreement
with most of your suggested changes, and I hope that we can
secure your commitment here today, and it sounds like we have
it, that we are going to continue to work through the remaining
issues.
Mr. Allen. Yes, sir, you have it, and thank you for your
interest in safety. I appreciate that.
Mr. Altmire. Thank you.
Thanks to all of you and thank you, Mr. Chairman.
Mr. Costello. The Chair thanks the gentleman from
Pennsylvania and now recognizes the gentlelady from Oklahoma,
Ms. Fallin.
Ms. Fallin. Thank you, Mr. Chairman.
Thank you all for coming today to present such valuable
information to help keep our airways safe and our patients
safe. We appreciate all that you do and your thoughtfulness in
giving us testimony today.
I had a couple of questions. One is to Mr. Allen. In your
written statement, it points to a number of voluntary
compliance measures that have been put in place by the FAA that
will address the safety issues and rulemaking later this year.
What issues specifically is the FAA going to address in the
rulemaking?
Mr. Allen. Good question, ma'am. Thank you. Actually, many
of the things that we have already implemented on a voluntary
basis, but I will go through a quick list of things that we
intend to put into the rulemaking. First and foremost, and I
know will make Mr. Sumwalt very happy, is HTAWS, the Helicopter
Terrain Awareness Warning System, that I said 40 percent of the
industry have already implemented voluntarily, 41 percent,
actually. The use of radar altimeters. For those operators that
have 10 or more aircraft, to have an operational control
center, dispatch center. To put in the rulemaking what we are
already prescribing under operational specification, that is,
the use of Part 135 weather minima for all legs of an air
transport operation. Implementation of risk management
programs. To require flight data monitoring devices on the
aircraft. We call them cockpit voice recorders and digital
flight recorders. And also inadvertent IMC, meaning weather
recovery demonstration, brownout, whiteout, flatout lighting.
We found that many accidents are attributed to inadvertent
entry into weather situations that the pilots weren't
appropriately trained on, so that would be required in the
regulation. And we have some other things that are more of a
detailed nature in terms of the training of passengers and also
better definition of what HEMS operators can do in terms of an
approach if weather is at low minimums.
Those are the primary aspects of the regulation, and there
will be other things that we will most likely consider as we go
out for comment and receive those comments.
Ms. Fallin. So let me ask a follow-up question. Do you
think that we need safety legislation or do you think you can
implement these things through the rulemaking?
Mr. Allen. Well, we are always very, very appreciative of
the assistance by Congress in the realm of safety, so we
believe that some aspects of legislation--Congressman Salazar's
bill, I believe we accommodate all of his issues, but if they
work together, then I think it buttresses the safety issue. So
we look, as we have said, to working with them to make sure
that they work in a conjoined path. So I don't think that they
hurt one another; I think that they help one another.
Ms. Fallin. Okay. I also wanted to ask a question about
some of the proposals as far as the night vision goggles and
things like that. How do you anticipate that some of the rural
communities that use these services and some of the rural
hospitals that might use ambulance services, how do you
anticipate they are going to pay for these extra expenses on
various mandates? I understand what you are trying to do, but I
am concerned about access to the care, especially for some of
the communities and some of the hospitals that may not be able
to afford, and even some of the helicopter companies that may
not be able to afford some of these changes.
Mr. Allen. Yes, ma'am. We share your concern, and that is
part of the reason why we are not requiring implementation of
night vision goggle systems. We have that as a voluntary
measure. There is a technical standard out there for the
implementation. We have wide voluntary application of that
technology. All the major HEMS operators already voluntarily
use them. In addition, we found, though, that we wanted to be
careful of just overly being prescriptive, because some
operators are not pre-dispositioned to use them. It takes quite
a bit of training and a change in their helicopter
infrastructure, so that is quite a transformation, actually, of
not only equipage, but also how you fly the helicopter. So,
therefore, we feel that that technology, as valuable as it is,
and there are a lot of voluntary initiatives to implement
those, we don't want to be prescriptive on that technology.
With this rulemaking, we will be prescriptive of HTAWS, but we
believe that it is a well vetted and analyzed technology that I
believe is so important that I believe it will be worthwhile
for all operators to employ.
Ms. Fallin. Mr. Sumwalt, how do you feel about that, as far
as requirements on those goggles?
Mr. Sumwalt. Congresswoman, we do not have a specific
recommendation at the NTSB regarding the night vision imaging
systems. At our public hearing in February, we received a good
bit of testimony on that, and some of the testimony indicated,
as Mr. Allen said, that night vision imaging systems can be
very helpful but should not necessarily be applied for all
operators. So that is one of the things that we are looking at
as we go through the testimony. We have not issued
recommendations directly on that.
Ms. Fallin. I appreciate all your testimony. If I could
just get a real short answer on what is the training that is
required to be able to use that? I assume that you have to go
through some specific training to know how to use the goggles.
How much time or course work?
Mr. Sumwalt. I am not a subject matter expert; I will let
Mr. Allen answer.
Mr. Allen. I have to admit, ma'am, I am not a user of the
night vision goggles, but from those that I work with and work
for me, it is a bit of a training requirement to understand how
you would transition, say, from instrument conditions to visual
conditions; how to train against what we call a brownout or
whiteout or lights flashing. Now, the technology is getting
better and those issues aren't as tough to solve as they were
in the past, but there is a reasonable substantial human
factors training requirement for that.
Ms. Fallin. Okay.
Mr. Sumwalt. I believe it is about a week. I was at Bell
Helicopter in November, and it was about a week long ground
school, with some flying as well.
Ms. Fallin. Okay. Well, that is better than I thought.
Thank you.
Mr. Costello. The Chair thanks the gentlelady and now
recognizes the gentlelady from Hawaii, Mrs. Hirono.
Mrs. Hirono. Thank you very much, Mr. Chair.
I know that we are all on the same page in wanting to make
sure that safety is the first issue that we have to address.
There has been testimony that indicates that, as to the number
of accidents, we are not entirely sure what those accident
numbers mean. However, we do look to NTSB as the entity that
will investigate aviation accidents. Therefore, the
recommendations of NTSB are recommendations that I take
strongly to heart. I know that you are familiar, Ms. Fornarotto
and Mr. Allen, with NTSB's four recommendations. Mr. Allen, I
believe you said that the rulemaking that you are undertaking
addresses these four recommendations. So my question would be
where are you in the rulemaking process with regard to
implementing these four recommendations.
Mr. Allen. Yes, ma'am. We just initiated, we just were able
to sign off on a rulemaking initiative, and, to be honest with
you, the culmination of that rulemaking process will probably
come to fruition by 2011 for the rule to actually be codified
and be implemented. 2011.
Mrs. Hirono. Here we are 2009. Based on the testimony, it
seems to me that one of these bills, which mainly incorporates
the recommendations of NTSB, which is H.R. 1201, we know that
rulemaking takes time, and there are reasons that it takes
time, but would there be any harm, truly, in passing this
legislation that at least lays a foundation? The indication
also is, from GAO's testimony, that one of these
recommendations has already pretty much been implemented. So
why don't we push ahead, knowing that the safety of the users
of HEMS is primary? Why not just push ahead with this
legislation?
Mr. Allen. I have no argument, ma'am, with this. We look
forward, as I said, to having all the support that I can get in
helping safety.
Mrs. Hirono. Thank you.
Thank you, Mr. Chairman.
Mr. Costello. The Chair thanks the gentlelady and now
recognizes the gentleman from Ohio, Mr. Boccieri.
Mr. Boccieri. Thank you, Mr. Chairman.
And thank you to the panel for establishing a discussion on
this very important legislation. I, at my Air Force Reserve
base, we fly with pilots who also fly with medical emergency
system here and then fly into Mr. Altmire's district and bring
patients. After conversing with them on a number of occasions,
especially surrounding some of the accidents that have
occurred, it seems to me that there is a willingness, if not a
sense of urgency, by the pilots to do all that they can to get
to that medical emergency and try to save the life of that
person. So I know that many of the accidents and the
information that you have suggested it is pilot error, flying
controlled flight into terrain, but there is a sense of
urgency, and I would hope that the FAA, in recognizing the
importance of this legislation and developing the flight risk
evaluation program, that you will take into consideration that
sense of urgency that these pilots have to get to that
emergency.
A question. First of all a comment. Congresswoman Fallin
from Oklahoma suggested about the type of training that is
involved with night vision goggles. Being very proficient in
this, we have to go through exhaustive training, working with
crew resource management, working with our crew members to have
semi-annual requirements, as well as quarterly requirements to
meet the training requirements of the Air Force, which I am
certain that you will apply some sort of military connection to
the training that you have, since they are widely operational
use by the military, and especially our Air Force and DOD
helicopter pilots.
My question to you, Mr. Allen, is you said in your
testimony that the impact of a positive safety culture on
operational safety must be recognized by the entire HEMS
industry. I hope that you will take into account my
perspective, and I ask you is there any technology out there
that is being experimented on that allows for a vertical
instrument landing system, where the folks can hover down to
the emergency spot? I know that the military employs like
microwave landing systems, portable instrument landing systems.
Is there any of that type of technology on the forefront?
Mr. Allen. That is technology that we are assessing, but we
have not assessed it in terms of application to the HEMS
industry. We have looked at it in other facets of the aviation
industry. We are looking at all types of new technologies and
their application. Actually, a lot of them come to us from
industry who would like to employ them, and we look at them,
analyze them, and look at their application to the industry.
But, to my knowledge, at this point, we haven't looked at
microwave landing systems, the vertical descent systems, but
those are something that obviously we will take a look.
Mr. Boccieri. Thank you. How soon do you think that this
technology can be employed or will be employed once you
evaluate your program? Is it something that can be online
relatively quickly?
Mr. Allen. Any new technology takes quite a bit of vetting.
HTAWS, for instance, took several years because of a new
application of a technology that I have also used in the
Reserves, TAWS, had to be reassessed and new standard produced
for application in this new environment. So it does take quite
a bit of time to get a consensus, to get the standards defined,
and then to get them implemented. So I can tell you, as I share
Congressman Costello's concern about the length of time for
rulemaking, also, application of new technologies has to go
through due diligence. So I cannot promise you that it would
happen overnight.
Mr. Boccieri. Thank you, Mr. Chairman.
Mr. Costello. The Chair thanks the gentleman from Ohio and
now recognizes the gentleman from Boston, Mr. Capuano.
Mr. Capuano. Thank you, Mr. Chairman.
Ms. Fornarotto, I have 45 very difficult questions for you,
but Mr. Costello won't let me ask them. I really don't have too
many questions. I actually appreciate the fact that you are all
working on this and trying to work this out. The Committee has
talked about this in the past and it is an issue that is
obviously very important to all of us, me included. We all have
med flights of some sort that work, and I understand the
difficulties.
But I also want to be clear that I have yet to find any
regulator in any business who doesn't over-regulate, doesn't
have a tendency to do so, I should say. For instance, there
isn't a single firefighter in Boston who would let anyone in
Boston ever park a car on the street, because it might get in
the way of a fire truck somewhere along the line. Of course
there are rules and regulations about within certain feet of
the intersection, and those are all reasonable.
What I am trying to say is, as you go about this, please
try to be reasonable. Please try to realize it could be your
family members on that med flight that you need to get to a
hospital, and it is not just a regular flight. This is not U.S.
Air bringing me home. This is an emergency situation with a
loved person on that helicopter that needs emergency medical
response.
So as you go about this, I am begging you all--I am not
suggesting you take your hats off as aviation safety people. I
am simply saying that you understand this is unique. This is
not a private enterprise, per se. And the slippery slope
doesn't bother me on this one. This is a serious and
unequivocal potential exception to any rules you might have,
and I am begging you all to look at it that way; not just
through the prisms that you have all looked at what you do. You
all do a good job. I feel very safe in the skies. I know the
NTSB does a great job reviewing every accident that I have ever
seen. You do a fantastic job. But I am just simply saying
please, as you look at this, understand this is a unique and
special situation that does demand your attention, more than
just air safety professionals.
I also understand very clearly--and, again, I am not
pushing them today because I do think it is fair to ask for
time, but some of the things that concern me. Different States
do have different levels of interest in medical care. In
Massachusetts, we don't ask people, when they come in to the
emergency room, whether they have insurance. Now, I understand
that is a State law, that is not a Federal law; it is the way
we like to do things. We don't want to deny anyone health care.
I would also say the same thing about a med flight. I wouldn't
want a helicopter service saying, well, what kind of insurance
do they have. And, again, if a State wants to regulate that, I
don't see that as an FAA or a safety issue; it is a health care
issue that has nothing to do with it. An ambulance service in
Massachusetts is required to provide 24/7 coverage. The last
thing in the world, if your loved one is sitting in a car wreck
or has a heart attack in the middle of nowhere, or whatever it
might be, you don't want to hear, well, we are sorry, yes, we
do this, but we are not doing it right now. Again, if an air
carrier wants to stop flying at 9:00 at night, so be it; that
is life. I have got to wait until the next morning. I don't
want to hear that for my mother or my child, and I don't think
any of you would either.
So there are many things that I simply want to say now, in
public, that, as you go about this, please, please recognize
there are things. This is not a commercial air flight. And as
far as competition goes, I am all for competition. At the same
time, that competition has to be on the basis of what is fair
and equal for competition, number one; and, number two, for, in
this case, health care as well. For instance, I don't know the
answer, I am not even looking for an answer right now, but as
we go forward, if, for the sake of discussion, XYZ air carrier
decides to get into this, will they be treated the same as if
the St. Elsewhere Hospital decides to have their own med
flight? And the answer should be yes. I can't imagine they
wouldn't be. And I understand that different forms of business
might be seen differently, but, again, in this case, it is an
exception to the rule. St. Elsewhere wouldn't be carrying--
actually, if they wanted to get into the airline industry and
bring me home every other week, then they should be subject to
the same regulations. But if the air carriers are going to get
into competition, then the competition should be fair and
equitable as well, on as many planes as you can get.
Again, I understand fully well that you are all working
towards this, and I think it is fair and reasonable that you be
given an opportunity to come up with regulations, let people be
heard on them, but as you do, I just want to reemphasize that
you do this knowing that this is potentially a serious
exception to the generic rules that you would normally operate
under. Thank you very much.
Mr. Costello. The Chair thanks the gentleman and now
recognizes the gentlelady from California, Ms. Richardson.
Ms. Richardson. Thank you, Mr. Chairman.
Two questions. First of all, in the next panel that is
coming forward, according to Ms. Friedman's testimony, the
States, the NTSB's 2006 study found that 55 accidents that it
studied, none of the operators involved required a completion
of a standardized flight risk evaluation prior to flying. Is
that your understanding as being correct?
Mr. Sumwalt. Who is the question directed to?
Ms. Richardson. Probably, first of all, to our Acting----
Mr. Allen. Well, actually, ma'am, maybe it is more toward
on the safety side, I believe it is correct. I don't have the
stats in front of me, but we did find, when we did the survey
of our operators, that there was a risk assessment program that
was accommodated by 94 percent of the HEMS community. I don't
know if that answers your question, but I believe it does.
Ms. Richardson. No. Specifically, my question is, according
to the NTSB study, it found that out of the 55 accidents that
it studied, none of the operators involved were required to
complete a standardized flight risk evaluation. Is that true or
is that not true, or do you know or do you not know?
Mr. Sumwalt. Well, I will answer that. I am from the NTSB
and that is a factual statement.
Ms. Richardson. Okay. Do you see that as being a problem?
Mr. Sumwalt. Absolutely, and that is why we issued a
recommendation to require flight risk evaluation. We found that
of the 55 accidents that we evaluated, 14 of them, we feel,
could have been prevented if a flight risk evaluation had been
performed. Furthermore, as you indicated, none of the 55
flights that we looked at had that flight risk evaluation,
which indicates that, at the time of these accidents, there was
not a lot of compliance with using that recommendation. So we
do feel very strongly that flight risk evaluations should be
required.
Ms. Richardson. Mr. Allen, is there any reason why we
wouldn't implement this now, instead of waiting until the end
of 2009, in 2010?
Mr. Allen. Well, yes, ma'am. Actually----
Ms. Richardson. It seems to be a pretty obvious problem.
Mr. Allen. Yes, ma'am, it is a problem. We share the
concern with the NTSB as well. That is why we, as I said, set
in place this as a voluntary measure. We have had excellent
voluntary accommodation of the requirement for a risk
assessment program. That is also included in our rulemaking.
Now, I know as far as an actual requirement, many people look
at that as being a rule, but the rulemaking process does take
time for reasons that have been articulated here, that we have
to take into consideration many stakeholders' perspectives on
the issue and we have to do a thorough analysis on the impact
on the industry and on the public. So that is why that takes
time.
So we have many tools that we can apply to the safety
equation, rulemaking being one, but voluntary measures being
the other. So I would submit that when the NTSB brought this
forward, at the time, yes, they were not employing these
things, but now, if we go back and reassess that, I would argue
that they are employing these risk assessment programs and that
safety is being served.
Ms. Richardson. Would you agree with that?
Mr. Sumwalt. That is a reasonable approach. What is your
voluntary compliance right now?
Mr. Allen. Ninety-four percent, according to our survey.
Mr. Sumwalt. Ninety-four percent now, versus a few years
ago where zero percent was complying. So we feel that we do
want the regulation to make sure that it is 94 percent, it is
100 percent, but 94 percent is better than zero percent.
Ms. Richardson. Okay. Well, let it be said for the record
that, to me, an issue as serious as this shouldn't be based
upon voluntary. Whether it is 94 percent or 98 percent, it
should be 100 percent.
I want to applaud Mr. Altmire, who I think had a huge role
in this hearing taking place, and Mr. Costello for supporting
it. I have been studying his bill, H.R. 978 and am seriously
inclined to support it. One of the documents, though, that I
saw said that the AMOA claims that the Patient Safety Act will
lead to a decrease in aviation safety and allow States to
regulate aspects of aviation currently under Federal authority.
Clearly, this legislation would do that, but would you see it
as really leading to a decrease in aviation safety? Any of you,
if you would like to comment.
Mr. Allen. No, ma'am. That is why we are working very
closely with the staff and we are being very vigilant, that we
will not let that happen. And I know that we do not want that
to happen, so we are being very, very judicious and making sure
the legislation is directed to what it wants to be focused on
and that we maintain our responsibility and accountability for
having the overview of the safety issues in terms of aviation
safety.
Ms. Richardson. Thank you very much.
Mr. Costello. The Chair thanks the gentlelady.
Now, let me thank all of our witnesses. I do have a few
questions that I will be submitting for the record. We want to
get to the next panel. But let me thank you for being here
today and offering your thoughtful testimony. We obviously need
to continue to work to solution to this critical problem we
face. So thank you very much for being here and thank you for
your testimony.
The Chair will ask the witnesses on our second panel to
please come forward as quickly as you can. I will introduce you
as you are being seated.
On panel 2, Ms. Stacey Friedman, who is the Founder of
Safemedflight: Family Advocates for Air Medical Safety; Eileen
Frazer, RN, CMTE, Executive Director, Commission on
Accreditation of Medical Transport Systems; Ms. Sandra Kinkade,
who is the President of the Association of Air Medical
Services; Mr. Matthew Zuccaro, who is the President of
Helicopter Association International; Mr. Craig Yale, who is
the Executive Vice President, Air Methods Corporation, on
behalf of the Air Medical Operators Association; Mr. Jeff
Stackpole, Council Member, Professional Helicopter Pilots
Association; Thomas P. Judge, EMTP, Executive Director,
LifeFlight of Maine, Chair, The Patient First Air-Ambulance
Alliance; and Dr. Robert Bass, the Chair of the Air Medical
Committee, The National Association of State EMS Officials.
So, ladies and gentlemen, if you will take your seats as
soon as you can, we will hear your testimony.
We have all of our witnesses at the witness table, and the
Chair would now recognize Ms. Friedman.
Again, I would remind all of our witnesses that your entire
statement will appear in the record in its entirety, and I ask
our witnesses to try and summarize their testimony under the
five minute rule.
Ms. Friedman.
TESTIMONY OF STACEY FRIEDMAN, FOUNDER, SAFEMEDFLIGHT: FAMILY
ADVOCATES FOR AIR MEDICAL SAFETY; JEFF STACKPOLE, COUNCIL
MEMBER, PROFESSIONAL HELICOPTER PILOTS ASSOCIATION; EILEEN
FRAZER, RN, CMTE, EXECUTIVE DIRECTOR, COMMISSION ON
ACCREDITATION OF MEDICAL TRANSPORT SYSTEMS; SANDRA KINKADE,
PRESIDENT, ASSOCIATION OF AIR MEDICAL SERVICES; MATTHEW S.
ZUCCARO, PRESIDENT, HELICOPTER ASSOCIATION INTERNATIONAL; CRAIG
YALE, EXECUTIVE VICE PRESIDENT, AIR METHODS CORPORATION, ON
BEHALF OF THE AIR MEDICAL OPERATORS ASSOCIATION; THOMAS P.
JUDGE, EMTP, EXECUTIVE DIRECTOR, LIFEFLIGHT OF MAINE, CHAIR,
THE PATIENT FIRST AIR-AMBULANCE ALLIANCE; AND DR. ROBERT BASS,
CHAIR, AIR MEDICAL COMMITTEE, THE NATIONAL ASSOCIATION OF STATE
EMS OFFICIALS
Ms. Friedman. I want to thank Chairman Costello, Ranking
Member Petri, and Members of the Subcommittee for inviting me
to speak today on behalf of the families of Safemedflight. We
are a group of families who have lost loved ones in air medical
accidents.
We also want to applaud Congressman Salazar for working
with us, working with industry, and working with the FAA in
making this bill possible.
As I said, my name is Stacey Friedman. I am not a pilot. I
am not a flight medic. I am not a flight nurse. I don't work
for an air medical program. I am not with the FAA or the NTSB.
But I am here for one very important reason, and that is
because of Erin Reed. She was my sister and she died in a
preventable helicopter crash.
It has been three years since Erin died, and 45 more
victims have followed her in death, 35 in 11 months. Voluntary
compliance did not work for them. The absence of FAA rules did
not work for those people. These pilots, nurses, medics, and
their patients died, despite the NTSB's recommendations in
2006. They died despite the extensive GAO report on this
industry; they died despite Safety Board hearings; and they
died despite safety summits in which industry leaders met to
determine the least possible regulation their pocketbooks could
afford. Yes, I am a little angry. My husband told me to watch
it, but I am going to just do it the way I would do it.
The FAA and the industry originally claimed that safety
changes were unnecessary and too costly, and they said that we
were asking the impossible. If we were asking the impossible, I
wouldn't be here, Sandy Hellman would be here. She would ask
that you bring back Todd to help her raise their eight adopted
children with no life insurance and no lawsuit payout. Mason,
Weston, and Jackson Taylor would ask you to bring back their
dad to take them to a ball game. ER physician Stacey Bean would
ask that you restore her faith in air medicine, faith that she
has lost since the death of her husband, Darren Bean. She no
longer practices ER medicine. Susan McGlew would ask that you
bring her brother, Bill Podmayer, home so he could say goodbye
to his parents, both who died just weeks ago, and Susan buried
them. Adam Wells would expect you to bring back his wife,
Jenny, so they could start a family.
Bringing our people home, that would be asking the
impossible. Instead, we are asking the FAA and the industry to
do what is included in Congressman Salazar's bill. We ask that
operators fly the higher weather minimums and comply with pilot
duty rest time in Part 135. Why the FAA ever allowed flight
crews to fly in less safe weather conditions just because there
wasn't a patient on board is incomprehensible to us. The FAA's
recent change on weather minimums is years too late and no
guarantee that operators will not push weather in this
hypercompetitive market.
We ask that operators use a risk assessment prior to
accepting a flight. EMS flight risks are well known and
documented, and we have talked about them today. They include
weather, obstacles and terrain, nighttime flight, spacial
disorientation and pressure to take a flight. A longstanding
FAA notice required operators to complete a risk assessment.
Yet, recently, at least two fatal accidents, killing eight
people, involved operators who failed to comply with this
notice: Alaska in December of 2007; Illinois in October of
2008. Why are operators who violate FAA notices and kill flight
crew and patients allowed to operate? That is a question we
have.
We ask that flight dispatch and flight following procedures
be required and that dispatchers have aviation specific
knowledge. In June, a midair collision in Arizona killed seven.
Both aircraft were scheduled to arrive at the same helipad
within minutes of each other, yet, neither pilot received this
information.
We ask that EMS operators carry cockpit recording
technology to determine the cause of accidents, prevent future
accidents, and answer the questions of family members. We ask
that operators install existing and proven technology that
helps pilots avoid terrain and collision with obstacles, and we
include night vision goggles in this category.
We are not asking the impossible. We are asking operators
to keep our people safe. And if their response is we can't
afford it, then they shouldn't be in a business that rests its
reputation on saving lives.
To close, I would like to tell you something about what I
believe happened on September 29th, 2005. That night changed
everything for my family and left me without my sister. I
believe the pilot, Steve Smith, did everything he could to keep
Erin and Lois alive. And I believe the circumstances of that
evening got the best of them. I believe that if they had had
the technology and the systems in Congressman Salazar's bill,
as well as night vision goggles, they would be alive today, and
I believe dozens of others would be alive today as well.
I want to thank you for giving us a voice at this hearing.
Mr. Costello. Ms. Friedman, thank you. Thank you for being
here on behalf of Erin and the other victims.
The Chair now recognizes Mr. Stackpole.
Mr. Stackpole. Good morning. My name is Jeff Stackpole. I
am currently working as a full-time line pilot flying an
emergency medical services helicopter in the St. Louis,
Missouri area for our Chair Medical Services, a wholly-owned
subsidiary of Air Methods Corporation. I am also the President
of Air Methods Pilots Union, Local 109, of the Office of
Professional Employees International Union. By virtue of that
office, I serve as a council member of the Professional
Helicopter Pilots Association, the organization you have
invited to participate in today's hearing.
PHPA represents approximately 400,000 helicopter pilots, of
which 1500 or so are working HEMS pilots. On behalf of those
dedicated professional men and women, I would like to thank the
Committee for focusing its attention on the difficulties
currently being experienced by our industry. While this is
certainly an important subject for all involved in this
process, no one has as much at stake on the outcome as do the
pilots we represent. Likewise, we believe, no one has as much
to contribute to the process of figuring out how to improve the
safety of this industry than those who perform the job on a
daily basis.
While this is a complex issue with no simple solution,
solutions do exist, and action must be taken to ensure those
are implemented. PHPA has submitted to this Committee a
detailed list of areas of concern, as well as recommended
actions that we believe are necessary to achieve our common
goal, which is, of course, the reduction of preventable
accidents in HEMS operations.
While we would like to believe that the free market system
would resolve these issues for us by eliminating marginal
operators and rewarding those operators that spend the
additional funds necessary to properly equip, train, and
support the safest possible operations in what we all agree is
a much needed public service, this has proven not to be the
case. Unfortunately, those requiring air medical transport
typically have no input as to the operator that will be
utilized to provide that service, thereby economically
disadvantaging those operators who, in the interest of
enhancing safety, choose to provide more than the very minimum
required by statute to accomplish the task.
Another aspect of our industry that has the same effect as
that just described is that of reimbursements. It is our
understanding that neither Medicare, Medicaid, nor private
insurance offer any additional compensation based on the type
of helicopter utilized, the training and experience levels of
the crew, or any other safety enhancing initiative that one
operator may offer over another. Add to this the fact that
Medicare and Medicaid reimbursements often do not even cover
the costs of providing the basic service, it is not difficult
to understand the economic disincentive that exists for any
operator striving to achieve the safest operation possible.
In addition to these economic issues, our industry is
burdened with another issue not foreign to other aviation
operations, however, for us it is multiplied exponentially, and
that is the pressure to fly. For some, this pressure is
completely self-imposed by the knowledge that almost every time
a flight is requested there is a patient possibly in dire need
of our services. For others, unfortunately, there are external
pressures in the form of a customer questioning a pilot's
decision to decline a flight request.
While the FAA has made a concerted effort to address the
issue of operational control, it is the opinion of PHPA that
this effort needs to go further. For example, we believe that
it is inappropriate for a hospital customer to participate in
the process of selecting the pilots that their vendor chooses
to provide, and that it is equally inappropriate for a hospital
customer to have the ability to have a vendor remove a pilot
from their program without justification. It seems overly
apparent to us that this type of arrangement can and does erase
the lines of operational control that are vital for the
certificate holder to maintain.
PHPA and the pilots we represent appreciate the efforts of
those Members of Congress who have introduced legislation
addressing safety issues in HEMS operations. And while we do
not disagree with the contents of the current bills, we feel
that stronger, more comprehensive language is necessary to
bring about the improvements we are all hoping for. In spite of
the fact that most helicopter pilots are conservative in nature
and would normally agree that less government involvement in
our business is better than more, we find ourselves conceding,
at least in this situation, that government intervention may be
the only way to achieve any real progress.
We ask that you review the information we have submitted
and consider addressing as many of the concerns we have raised
as you feel may be appropriate in any current or proposed
legislation. Thank you for inviting the Professional Helicopter
Pilots Association to address this Committee, and please call
on us for any assistance we may be able to provide in advancing
this important effort.
Mr. Costello. The Chair thanks you and now recognizes Ms.
Frazer.
Ms. Frazer. Thank you, Mr. Chairman. The Commission on
Accreditation of Medical Transport Systems was formed in 1990,
after a rash of accidents that occurred in the mid-1980s. It is
a voluntary, not-for-profit agency. We have 17 member
organizations. Each member organization sends a representative
to serve on the board of directors, and all of those represent
all of the constituents within medical transport.
The most important part of what we do is accreditation
standards. These standards are used worldwide because it is the
only body of standards that look over the wide range of
programs within an air medical and ground transport service.
They cover things like patient care, crew training, staffing,
scheduling, management, aircraft medical configuration,
communications, helipads, quality management, safety management
systems, infection control, and so on.
Every two years, we revise the standards to reflect the
current dynamic changes, and in developing and revising
standards, we do talk with the NTSB, our Federal partners at
the FAA, we get input from all of our constituents and groups,
and we can move quite quickly with standards. For example,
after the rash of accidents last summer, the board met and we
looked at some of the preliminary reports that came out by the
NTSB. In looking at those, we quickly developed some standards,
especially looking at fatigue, which was really a concerning
issue not only for night flights with the visual and the
weather conditions, also fatigue, we felt, was a really strong
concern. We also addressed the hospital helipad communications
and better crew coordination with the helipads.
So those standards came out within six months and were
approved.
As far as the Federal partners, we are required by the
Department of Defense and we are required for civilian, medical
air transport contracts, as well as by Indian Health Services.
I want to talk about the States a little bit because that
is addressed and was discussed earlier. There are currently
five States that do not have any air ambulance licensing
procedures at all. In nine States they require CAMTS
accreditation, and those States are Colorado, New Mexico, Utah,
Washington, Michigan through their CFN process, New Hampshire,
Rhode Island, Massachusetts, and Maryland. So, currently, there
are nine States that require CAMTS accreditation. Some counties
in California and Clark County in Nevada.
This absolutely puts us, though, in a litigation process,
because if we withdraw accreditation in those States, that
means that company is not allowed to operate in that State and,
therefore, we have a legal issue. So we are working with those
States on those issues right now. We do support the States.
They do have the responsibility for the health care of the
individuals on board.
As far as the Salazar bill, all patient mission flights
under our standards must be conducted under Part 135
regulations. We have had that since 2006. We also require
operation risk analysis tools and specifically check that each
time we go out and visit a program.
That concludes my testimony. Thank you.
Mr. Costello. The Chair thanks you, Ms. Frazer, and now
recognizes Ms. Kinkade.
Ms. Kinkade. Mr. Chairman, Ranking Member Petri, and
Members of the Subcommittee, thank you for the opportunity to
share our perspective on the topic of oversight of helicopter
medical services. I am Sandra Kinkade, President of the
Association of Air Medical Services, or AAMS. During the course
of my career, I have worked as a flight nurse in Nevada and
Tennessee for 13 years, and now have my own international
consulting firm.
Established in 1980, AAMS is a longstanding trade
association representing 300 air medical transport services
using both helicopters and fixed wing airplanes operating out
of nearly 700 bases across the United States. Each year,
approximately 4,000 of our Nation's sickest and most critically
injured patients are transported.
Most people don't realize the life and death role that
emergency medical helicopters play in our health care system,
but the critically ill and injured are airlifted once every 90
seconds in our Nation. That is why it is important not to
underestimate the value of air medical services, because the
life saved might be yours or a loved one's.
I would like to remind the American public of the following
important facts related to air medical services in the United
States today. Helicopter EMS provides safety, speed, access,
and quality of patient care, and serves as the rural health
care safety net, particularly in underserved areas. Medevac
helicopters provide a quicker response and a higher level of
medical care than is typically found on a ground ambulance. A
typical medevac crew consists of a specially trained critical
care nurse and paramedic, and can also include other
specialists, as needed, depending on the patient's condition.
In rural or wilderness areas, or in cases of natural or
catastrophic disasters, air ambulances may be the only
accessible health care provider available.
Medevac helicopter crews do not self-dispatch; a flight
request is generally made by a physician, nurse, law
enforcement officer, fire service or emergency medical
responder, as dictated by local, regional, or State protocols.
Demand for medevac helicopters is on the upswing, partially as
a result of aging baby-boomers whose related health care
problems, most notably stroke and heart attack, are placing a
greater demand on the overall health care system, as well as
creating a need for highly time dependent emergency medical
interventions. Greater reliance on medevac helicopters is
particularly prevalent in rural and retirement areas, and in
places that have experienced emergency room closures or
cutbacks in local community-based ambulance services or
hospitals.
Clearly, the goal of air medicine is to improve health
outcomes for our patients. Our goal has been, and continues to
be, zero accidents. To that end, the industry has undertaken
numerous voluntary efforts to advance safety on each and every
mission. Additionally, we have put forward several proposals
aimed at making medical helicopter flights safer. Chief among
these proposals is that all medical night flight operations be
required to either utilize night vision goggles or similar
enhanced vision systems, or be conducted strictly under
instrument flight rules.
AAMS recommends that Congress expedite funding for hospital
helipads, enhanced off-airport weather reporting, global
positioning system technologies, and other initiatives. AAMS
recommends that the FAA accelerate implementation of automatic
dependent surveillance broadcast systems, also known as ADSB,
for the HEMS operating environment. In addition, implementation
of associated weather reporting and enhancements to the
Nation's low altitude aviation infrastructure should become an
FAA priority. Further, AAMS recommends that the FAA, in
coordination with the industry, establish requirements and
procedures for utilizing devices that play a role in flight
operations quality assurance programs, also known as FOQA.
AAMS commends Congressman Salazar's current initiative to
advance helicopter EMS safety in introducing H.R. 1201.
Overall, AAMS is supportive of anything that will help make our
community and the missions we conduct safer. We have made some
recommendations in our written testimony that we believe will
strengthen the language and are very happy to hear from the
Congressman today that some of those recommendations have been
included in the recent bill changes.
AAMS and its members believe that the only appropriate
safety goal for this community is one of zero accidents. We
stand ready to work collaboratively with legislators,
regulators, and the public to combine our best thinking and
target our efforts to maximize the effectiveness of safety
initiatives and to dramatically lower the risks associated with
air medical transportation.
I just want to thank Stacey for being here and your
leadership and giving a voice to those who no longer can.
Mr. Costello. The Chair thanks you for your testimony and
now recognizes Mr. Zuccaro.
Mr. Zuccaro. Good morning, Chairman Costello and Ranking
Member Petri. Thank you for the opportunity to speak with you
today.
I would like to acknowledge one fact that I truly believe
that everybody that is in the room today shares a common goal
towards the enhancement of safety. I believe we acknowledge
also that we have differing opinions as to how to reach that
goal. My comments are made in respect to those opinions.
HAI represents the international helicopter community. It
is a not-for-profit professional trade association with over
2,900 members, inclusive of 1,400 companies and organizations.
HAI members safely and professionally operate in excess of
5,000 helicopters, fly more than 2 million hours per year.
We represent 93 medical service providers providing service
throughout the United States. These operators are comprised of
74 commercial operators, 17 government service operators,
flying a total of 1,219 aircraft, which we estimate represents
90 percent of the helicopter EMS operations being conducted in
the United States.
HAI, in fact, believes the current emergency medical
services accident rate is unacceptable and that these recent
series of accidents were preventable. We fully support any
initiative that improves the safety of EMS operations and
recommend a cooperative effort between industry and FAA, with a
resulting FAA rulemaking initiative, as necessary, to achieve a
safer EMS industry. In recognition of this, HAI has worked with
EMS operators to mitigate accidents, emphasizing safety
management systems, extensive use of them, emphasizing risk
management. HAI has been instrumental in working also closely
with the FAA in developing long-term initiatives addressing
such issues as 135 versus 91 operations on all the legs,
utilization of such technology as night vision goggles, radar
altimeters, HTAWS, devices that perform the function of CVR/
FDR, operational control centers, and formalized risk
assessment/hazard mitigation programs.
HAI has also been an industry leader by sponsoring numerous
safety forums that were focused on helicopter EMS operations.
Participation in these forums also involved industry, as well
as executive level representation from the FAA and the NTSB,
all working towards our common goal of enhanced HEMS safety.
HAI has also committed resources and staff in the efforts of
the International Helicopter Safety Team, a worldwide
international industry initiative with a goal of reducing
helicopter accidents by 80 percent within the next 10 years. I
am honored to serve as the co-chair of this international
effort, which is a data driven analysis process and was modeled
after the successful CAST program utilized by scheduled air
carriers.
As a result of a recent in-depth collaborative industry/FAA
effort, coordinated by HAI, FAA revised Part 135 HEMS Ops Spec,
A021, setting forth detailed flight planning and increased
weather minimums for HEMS operations.
Of equal importance, we strongly believe there is a need to
secure Federal funding for remote weather stations that would
fill existing gaps, especially at night, and the availability
of off-airport automated weather reporting stations to support
helicopter HEMS. There is also a critical need for a dedicated,
low altitude IFR helicopter route structure with the associated
instrument helicopter approaches to hospital heliports and
other locations such as accident scenes. This will provide all
weather helicopter instrument flight capability for emergency
services in the public interest, which is consistent with the
public expectation and the necessity for such services. Any
funding initiative should be inclusive of research and
development of advanced technologies to facilitate this
capability.
Earlier last year, the National Transportation Safety Board
completed a four day safety hearing on the subject of HEMS. HAI
was a designated party to and witness at the hearings, and
continues to serve as a major contributor to the NTSB/FAA
efforts. Of note, 80 to 85 percent of the accidents, when
studied, related to human factors decision-making, not to
technology and not to regulatory deficiencies. That is an area
that we all need to concentrate on, the actual way the business
is conducted and the human factor decision-making that occurs
within it.
H.R. 1201, the Salazar legislation, aims to increase safety
for crew and passengers on aircraft providing emergency medical
services, and would require EMS pilots to comply with 135
regulations whenever there is a medical crew on board,
regardless of whether a patient is also on board. There is some
distortion in the statistics. I would quickly point out that
when the NTSB categories an accident and notes that there is no
patient on board, they automatically put in Part 91 operation.
That may not be the case. It does not recognize the fact that
the operator was actually operating under Part 135, and that is
not noted.
HAI believes the actual question that should be addressed
regarding medical personnel and the conditions when they are on
board the aircraft relates to their status, as to whether they
are passengers or crew members. Once a resolution is reached on
this issue, then the proper regulatory guidance can be applied,
be it FAR Part 135 or 91. HAI believes that Congress should
task the FAA with resolving this matter.
We are a strong advocate of flight risk evaluation,
including usage of standardized checklists, risk evaluation to
determine whether a flight should be conducted. A collaborative
effort between the FAA and the air medical community should be
undertaken to develop performance-based flight dispatch
procedures and methods to measure the compliance. As
appropriate, feasibility studies should be conducted by the FAA
administrator on devices that perform the function of recording
voice communication and flight data information on new and
existing aircraft.
With regard to FAA rulemaking itself, it should be the
venue to effect safety initiatives and not legislative action.
We do acknowledge the current FAA rulemaking process is really
not acceptable in terms of the length of time it takes to
effect a rule change. Clearly, the FAA rulemaking process is
not timely and needs to be revised. Accordingly, Congress
should direct the FAA to review its current rulemaking
procedures and revise the same to expedite the implementation
of beneficial safety initiatives when appropriate.
I would point out that there is a system and it is not
functioning the way it should, and we should not circumnavigate
it with legislative initiative. Fix the system and make it
operate properly so that we can maintain the notice of proposed
rulemaking process.
Mr. Altmire's legislation, 978, is asking for a change as
it relates to health planning and patient safety to allow
States to regulate aviation operations, which are already
covered. The Department of Transportation has concluded that a
State is free to regulate the medical issues associated with
EMS service, including establishment of minimum requirements
for medical equipment, training, and personnel. We highly agree
with that. The bill does not really seem to address the safety
deficiency, but rather an economic regulation and resultant
entry control limits as to who can conduct the EMS, thereby
eliminating robust competition so required by the public
interest.
Helicopter operators do not decide who to transfer or
transport; the medical community does that. Where is the direct
correlation or research that indicates the number of HEMS
accidents in a given area is directly related to the number of
providers in that area? What about the potential impact of H.R.
978 on other segments of the industry and other types of
helicopter operations that find a necessity to cross State
lines that would ultimately be affected by this? Congress
should not allow the States to regulate the issues.
The unanswered question should be H.R. 978, how will it
make EMS aviation safety for the better?
With that, I would close my comments, Chairman, and be glad
to take any questions.
Mr. Costello. The Chair thanks you and now recognizes Mr.
Yale.
Mr. Yale. Thank you, Mr. Chairman, Members of the
Subcommittee. My name is Craig Yale, and I am Vice President of
Corporate Development for Air Methods Corporation. I am here
today on behalf of the Air Medical Operators Association, or
AMOA.
AMOA represents air carrier certificate holders providing
medical transportation operations, whether their fleet size is
a few or several hundred aircraft. On behalf of our members and
the over 8500 employees represented by the Association
nationwide, I would like to thank the Members of the
Subcommittee for the opportunity to offer this testimony and
your interest in air medical transportation safety and
effective oversight.
I too am very passionate about this subject. I have over 30
years experience providing medical transport. My experience in
that time encompasses both profit and not-for-profit
organizations providing helicopter, fixed wing, and ground
ambulance services.
Air Methods Corporation, with approximately 350 aircraft
operating in 42 States across the Country, is not only the
world's largest commercial air medical company, but by fleet
size is the tenth largest air carrier in the United States, to
include the major airlines. Air Methods operates through both
community-based air medical transport services, at the request
of others without knowledge of the ability for our patient to
pay, and as a contract aviation service provider to hospitals
engaged in air medical transport services.
The Air Medical Operators Association was formed to
coordinate and enhance the collaborative efforts of Part 135
medical air carriers on matters of safety, access, and quality
operations. AMOA's members represent the air carrier operations
of over 700 medical aircraft and approximately 92 percent of
the civil helicopter medical airlift capacity in this Country.
Many of these aircraft are utilized by hospital programs as an
indirect air carrier, and I will not presume to speak for these
entities, as there are others on the panel here for that
purpose. However, it is important to understand that Part 135
air carrier responsibility for the overwhelming majority of
these programs rests with AMOA's members.
AMOA strongly supports the intent of H.R. 1201. The
provisions of H.R. 1201 are rooted in safety recommendations
made by the NTSB's special investigation report on emergency
medical service operations adopted in January of 2006. The
recent public hearings held by the NTSB reviewed both the FAA's
and the air medical industry's response to those
recommendations. As evidenced by the hearings, we believe that
the air medical operators have met, and in some cases exceeded,
the intent of those recommendations. We are in favor of
codifying these advances through regulation, but would suggest
the use of rulemaking process to avoid unintended consequences
of the rigid interpretation potential there is in legislative
language.
As an example, all operations must comply with the
regulations of Part 135 of Title XIV, Code of Federal
Regulations, whenever there is a medical crew on board would
actually require less stringent weather minimums than those
currently in place through A021 Operations Specifications. We
agree with the need for regulation, but respectfully would
request the opportunity to fine-tune the process in conjunction
with the FAA through the rulemaking process.
We are, however, greatly concerned with the language and
underlying intentions associated with H.R. 978. All legal
interpretations and judicial rulings have clearly stated that
aviation operations fall within the Federal purview, while
States maintain control and responsibility for medical
operations. Since the State's right to oversee medical
operation of helicopter services is uncontested, it would
appear that the intent of this legislation ultimately distills
to an attempt to control and restrict the entry of air medical
operations within a State's boundaries.
Quoting a representative of the U.S. Department of Justice
Antitrust Division, certificate of need laws pose a substantial
threat to the proper performance of health care markets.
Indeed, by their very nature, CON laws create barriers to entry
and expansion, and are thus anathema to the free market. They
undercut consumer choice, weaken markets' ability to contain
health care costs, and stifle innovation. He went on to say
that CON laws appear to raise particularly substantial barriers
to entry and expansion of competitors because they create an
opportunity for existing competitors to exploit procedural
opportunities to thwart or delay new competition.
It is interesting to note that of the six States currently
exercising CON processes as it relates to air medical services,
each State has fewer air medical services per capita than the
national average. Emergency preparedness is about capacity and
access. It is AMOA's belief that H.R. 978 would severely limit
this Country's timely access to air medical services and would
reduce the ability to flex a response as necessary for natural
and other disasters. States should in fact meet their
responsibilities to oversee medical components of emergency
services. However, the responsibility for oversight of the
Nation's air carrier operations needs to remain in the expert
hands of the FAA and DOT.
Thank you, sir, for your time.
Mr. Costello. The Chair thanks you, Mr. Yale, and now
recognizes Mr. Judge.
Mr. Judge. Good afternoon, Chairman Costello, Ranking
Member Petri, and honorable Members of the Committee. I am
Thomas Judge and am testifying on behalf of The Patient First
Air-Ambulance Alliance, PFAA, which represents 70 air medical
providers in 40 States, including several members of AMOA. In
addition to professional roles in air medicine, I have worked
in rural EMS systems for over 30 years. Assuring access to care
is a personal imperative.
The Alliance was simply created to improve the
accountability of the air medical system to patients and the
public. It is extremely regrettable that HEMS has ended up on
the NTSB's most wanted list. While significant progress is
being made in improving air medical safety, more must be done.
A strictly voluntary approach in which individual providers
define their own standards is not working, as documented by the
Flight Safety Foundation.
While we strongly support single system aviation safety
oversight by the FAA and recognize the contributions of the ADA
to commercial travel, we are here today because HEMS is a
unique sector of aviation. HEMS is an essential emergency
service within a system, more akin to a public utility than an
enterprise. In an emergency, the public must trust that every
decision on their behalf is made strictly on the basis of best
medical and aviation practice.
The public perception of the system and the reality however
are at odds. The public believes that all medical helicopters
have the same level of performance and aviation safety
technology. They do not. The public believes that if they need
air medical transport, the helicopter that arrives will take
them to the right hospital, the right physician at the right
time. That may or may not be true, depending on where they
live. The public believes that the helicopter will be staffed
by qualified medical crews with the latest medical technology
to provide them with critical care. There is no such guarantee.
Our testimony includes are all too common story of
uncoordinated care. While critics of H.R. 978 have said it
would lead to multiple State standards, we are actually seeing
the situation where individual providers set their own
standards and can challenge any imposition of public
accountability by claiming economic regulation preempted by the
ADA.
When I was the president of AAMS, I believed the industry
could self-regulate. I was wrong. The rapid growth of
providers, underlying economic challenges in air medicine, and
the use of the ADA to strike down State regulations have come
together as a perfect storm, compromising both patient and
aviation safety. We see providers based in locations by payer
profile rather than need, often resulting in geographic
maldistribution of services; providers maximizing flight volume
over patient and aviation safety due to the need to meet high
fixed costs; providers working outside the EMS system;
providers transitioning to less capable aircraft. For example,
in Kansas City, a twin engine fleet became a single engine
fleet, antithetical to the FAA's current efforts to incentivize
IFR.
As slide 1 shows, saturated competitive markets actually
work in contrast to the goals of ADA, actually increasing cost
to the health care system and to patients.
The intersection of Federal and State law over HMS is truly
unique. While the FAA must oversee aviation safety, HEMS is the
only area of aviation where the States have a role and
legitimate interest because the passenger is a patient
receiving critical care. Unlike other commuter operations, our
passengers are critically ill, so they can't be considered
informed consumers. HEMS is the only area of health law in
which States are limited or prevented from regulating as they
do all other health care services within their borders. Medical
helicopters are both ambulances and aircraft. State regulation
over ``medical'' is more than simply the medical care provided
in the helicopter. State regulation must encompass the entirety
of medical helicopter services, meaning system integration,
coordination, and quality.
States are currently prohibited by the ADA from fully
regulating medical services in the way they regulate all other
health care services. The ability of States to regulate the
``ambulance'' aspect of HEMS has been challenged in numerous
areas, leaving enormous gaps in oversight, lack of clarity over
what States can and can't regulate, and a chilling effect on
State regulators to strengthen or even enforce existing HEMS
regulations.
States can't require 24-hour availability, determine base
location, require scene transports regardless of insurance, or
require integration with the EMS system. How is the public
served by an emergency service system that does not guarantee
24 hour access? States can regulate the medical care and
equipment, but as Representative Altmire noted, in Hawaii,
quality, accessibility, availability, and acceptability are
impermissible under the ADA. Something as simple as requiring
climate control to prevent cold babies or a heart attack
patient has never been explicitly permitted and is currently
being challenged in North Carolina right now.
Contrary to assertions that 978 does not limit access to
needed services, it only applies to intrastate point-to-point
transport. Indeed, cross border operations occur daily and will
continue to occur if 978 is enacted.
Slide 2 further illustrates how this works, the interstate
operations. Massachusetts and Connecticut, with the fewest
number of helicopters, have the best trauma preventable death
outcomes in the Country. The number of helicopters is not
really at issue.
An unregulated market does not guarantee access to
emergency care. The assertions that this will limit access in
rural areas is just really untrue. All of the growth, as seen
in the ADAMS database, is actually in areas in the last five
years that are already served by helicopters. By establishing a
clear boundary, 978 will lead to a safer and higher quality
HEMS system, provide more accountability, and lead to a more
harmonized and predictable State regulation benefitting Federal
and State regulators and providers.
We also endorse 1201 as an essential means to improve
aviation safety. As with H.R. 978, there is an opportunity to
improve and strengthen the bill, especially around building and
supporting a low level IFR system.
In conclusion, HEMS is not an aviation enterprise, but an
emergency public utility. We strongly believe a rebalancing and
clarification of the lines of conflicting regulatory authority
are necessary if we are to effectively address and improve both
aviation and patient safety, and we appreciate your time.
Mr. Costello. The Chair thanks you, Mr. Judge, and now
recognizes Dr. Bass.
Dr. Bass. Good afternoon, Chairman Costello and Ranking
Member Petri. I am Dr. Robert Bass and I am testifying on
behalf of The National Association of State EMS officials that
represent EMS officials in the 56 States and territories. I am
an emergency physician. My day job is a State EMS director in
Maryland.
EMS and trauma systems, we know they save lives, and a
breakdown of those systems can cost lives. In previous decades,
helicopter EMS, or HEMS, as we call it, were well integrated
into our trauma and EMS systems. Today, in many States, that
integration is lacking and the system is broken.
In early 2000, shortly after Medicare improved its
reimbursement practices for HEMS, the industry began to
experience extraordinary growth throughout the Country.
Unfortunately, more helicopters doesn't always mean more access
or better care. In many cases, it simply means more helicopters
on top of one another in urban areas. Some HEMS operators have
been utilizing the preemption provision of the Airline
Deregulation Act in an attempt to dismantle the EMS and health
planning provisions in many States.
In addition to the ADA challenges, letters of opinions from
the U.S. Department of Transportation have provided conflicting
guidance on preemption issues. In one recent DOT opinion, they
recognized the authority of States to regulate basic staffing
requirements, qualifications of personnel, equipment
requirements, and sanitary conditions. However, in another DOT
opinion, requirements related to quality, availability,
accessibility, and acceptability were viewed as being
preempted. Other language has left States unclear as to the
extent to which they can require medically necessary, but
expensive, life-saving equipment.
The effect of the ADA related judicial decisions and the
DOT letters has had a chilling impact on State efforts to
regulate the medical aspects of HEMS. In many States, EMS
officials are increasingly concerned about time-consuming,
costly, and potentially damaging lawsuits. States must have
clear and sufficient authority to fulfill the public trust in
planning, coordinating, integrating, and regulating air
ambulances as a component of the overall EMS system, just as
they do for ground ambulances. This was a key recommendation of
the 2006 IOM report that was previously referred to.
The difference between aircraft operations transporting
passengers and those transporting patients are important, and I
would like to take just a moment to emphasize those
differences. First, while a medical helicopter is an air
carrier, first and foremost, it is an ambulance which provides
very sophisticated patient care. Second, while airline
passengers typically choose their mode of transport and
airline, EMS patients and their families generally cannot.
Third, HEMS providers must function as part of another system,
the EMS system, and that is necessary to save lives.
NASEMSO supports H.R. 978, which would provide States the
unambiguous authority to determine the need for and
distribution of HEMS resources, as well as to regulate other
essential medical aspects of HEMS, including the adequacy of an
aircraft to serve as an ambulance by addressing issues such as
access to the patient and climate control for vulnerable
patients.
We have heard concerns about H.R. 978, so allow me to just
take a moment to address a few of them.
First, opponents argue that the bill would limit access to
HEMS services in rural and underserved areas. We don't believe
that to be true. What it would potentially do is to enable
States to limit the number of helicopters in oversaturated
markets and improve access to HEMS services in other areas of
the State. Second, H.R. 978 doesn't tell a State it must
regulate or that, if it does regulate, it must regulate in a
certain way. The bill appropriately leaves that up to the
States. Third, H.R. 978 does not impede the interstate
transport of patients. Medical helicopters move across State
borders everyday, just as ground ambulances do. H.R. 978 does
nothing to change that. Fourth, H.R. 978 does not interfere
with the FAA authority to regulate aviation safety. Both the
Federal Government and the States are trying to protect the
same person who is both a passenger and a patient. Fifth, there
is a precedent for H.R. 978 in the exemption from preemption
that is afforded States with respect to motor carriers.
It is estimated that over 4.5 million patients have been
flown by medical helicopters over the past 30 years. The
medical care and rapid transportation provided by HEMS has
undoubtedly saved many thousands of lives. As reported by the
Institute of Medicine in 1999, an estimated 131 to 292 deaths
per 100,000 patients occur due to adverse events during the
course of routine medical care. The need for aviation safety is
clear. However, it must not negate the need for patient safety,
or many lives will be lost.
Our association believes that more clearly defined Federal
and State roles and authority would lead to safer and more
effective utilization of HEMS in the United States, and we
thank you for your consideration.
Mr. Costello. Dr. Bass, thank you for your testimony.
Mr. Stackpole, let me ask a couple of questions, if I can.
You state in your testimony that better guidelines for new HEMS
pilots training are needed to ensure that solo pilots are
properly prepared. Do you want to elaborate on that a little
bit?
Mr. Stackpole. Well, sir, I think that as we discussed
earlier today, as you heard in earlier testimony, HEMS is a
unique aviation operation, so no matter where a pilot comes
from or gains his initial experience to come to work at a HEMS
operator, he needs specific training in relation to the
operation he is going to be conducting, and, currently, there
are many operators that fly aircraft that don't allow for
training a pilot in an actual HEMS flight. In other words, he
is provided training prior to going on to the line, but once he
has gone through his initial training, he is basically turned
loose on his own.
Mr. Costello. You also say, and I quote, ``real change will
not occur through voluntary compliance, some initiatives must
be mandated.'' I would like you to elaborate on that as well.
Mr. Stackpole. Well, I mean, I have been doing this job for
nine years, and I started in a program, the program that I am
still working at. We have a multi-engine aircraft that is not
certified for IFR but does have full instrumentation. But I am
seeing at our program the degradation of the equipment that we
utilize. We are being reduced to single engine aircraft at some
of our outlying bases; open cockpit or no longer is there
separation. The aircraft that I fly is not only multi-engine,
but also is a cabin class aircraft, so I have complete
separation from the medical treatment that is occurring in the
back. I think that is a very important issue for the safety of
the HEMS flight. We are seeing new aircraft that are coming
online that don't have that, and we think that is something
that should be regulated.
Mr. Costello. Thank you.
The Chair now recognizes the Ranking Member, Mr. Petri.
Mr. Petri. Thank you very much and, again, thank you, Mr.
Chairman and all of the panelists for your testimony.
I really just have one question, and I don't know who I
should direct it at particularly. This is clearly a heart-
wrenching situation and there is an even broader aspect to it,
the loss of life of crew members and passengers is tragic. On
the other hand, you are in an emergency situation and someone
may be dying in an auto accident or because of heart failure or
some other thing that conceivably could be prevented if there
was quick action taken.
Is that an aspect of the problem too? Are there cases, do
we have any statistics where people could have been saved, but
the crew or the airline company said, well, we are going to
save the equipment and it really wasn't that dangerous, but we
are not going to go ahead and do it, and a family has lost
their father or their wife or some other thing? How do you
balance these sorts of situations is what I am asking.
In my own case, in our business, politicians are
competitive and they are always trying to push and take private
flights. We have a long list of colleagues who have died in
airline accidents, both helicopter and plane, all the way from
Hale Boggs, who is a famous figure around here still, to Paul
Wellstone, who evidently shouldn't have done that, but he was
trying to go to some meeting and the pilot went along with it,
and Don Pane just was shot at, pushing the envelope a little
bit over Mogadishu, fortunately survived; Nicky Edwards didn't
over in Africa.
These are tragic situations. How do we balance all this?
And I suppose you think about it all the time, but is there
another side to it in terms of people who are dead because they
could have been saved and weren't?
Mr. Zuccaro. I would like to take an initial stab at that.
Everything that has been spoken about here I think has to be
focused on the relation to the human factors issue and the
decision-making, and remove the technology and the regulatory
environment. I think that is where we find that most of the
accidents and the causal effects are, is how that decision was
made to launch on that flight and what the human factors are.
We are all human beings, and I think as has been noted by
several of the panelists that this is a special environment;
there is a life at stake, and I think that is a contributory
aspect to this as to the decision-making. Nobody wants to be
the one to say I can't go because of the weather or the
conditions, and realize that they might have a material effect
on the outcome of someone's life. We try to respond to that as
human beings, and that is one of the areas that we are
concentrating on in the safety initiatives, as well as
everybody on the panel.
But in order to try to get it to best capability, there is
a critical need to separate the medical environment and the
aeronautical environment and the decision-making. In my thought
process, you have to view the medical mission as a transport
mission. The pilot and the company are being asked to transport
an aircraft from A to B, and to do it safely and
professionally. I think we need to apply the logic that what is
going on in the back of the aircraft, be it medical, be it a
passenger for some other purpose, is not germane to that
aeronautical decision.
If you start building in the fact that, on this flight, it
is a patient's life might be affected versus a corporate person
might want to go from A to B, you start changing the model for
the decision-making, when the real question has never changed:
Can you do this safely or not from A to B? And the pilots need
to be in an environment that is removed from the medical
influence so that they truly are only asking and answering an
aeronautical decision-making question. And I think that would
go a long way to enhance the decision-making human factors
issue.
Mr. Costello. Mr. Judge?
Mr. Judge. Certainly, I work as a paramedic everyday, so I
take care of patients in a very rural area. Our State does
require us to be available 24/7 in the flight medical system.
They do not, however, require us to fly. They require us to be
integrated into the care system so that there is an option for
that pilot to be able to say no and still know that the patient
out there is going to get taken care of. So they require us to
have 24/7 availability in an integrated EMS system.
It is very difficult to get that kind of data. We
certainly look for the patients who need to be served that we
can't reach in appropriate times, and we build the system to
try to do that. That is why we put in IFR. That is why we put
in NVG. That is why building an IFR infrastructure is so
important. But there is a balance that we have to do; not put
pressure on the pilot, find another way. But the only way you
can do that is to have a fully integrated EMS system from top
to bottom, with the air medicine part of that fully integrated
within the regulation.
Mr. Costello. Mr. Yale, did you want to comment?
Mr. Yale. I would echo the comments that have just been
made, but add to it that it is a balancing act that we need to
look at when we deal with the requests that you were talking
about. There is both a risk benefit and a cost benefit that
needs to be looked at and the ability to be able to respond. It
is important that we build systems that are capable of meeting
the need in our area; that we build systems that have the
ability to sustain that ability to meet that need; and that we
do it in the safest way possible. But I think that the real
critical component to pull away from this, as Matt suggested,
is that we need to recognize that, when it comes to the
transportation of the patient, we need to deal with that from a
decision can we go, pick up that patient, and bring them and
the crew back safely and complete that mission. If we think we
are taking a risk in putting that patient or our crew in harm's
way to do it, then we are making a mistake.
Mr. Costello. Ms. Frazer?
Ms. Frazer. Yes. We do have a standard that says the pilot
should be insulated from the decision-making that has anything
to do with the patient, and typically what we were trying to
insulate the pilot from are things like there is a child--which
typically brings a lot of emotion--that really needs our help.
So the decision-making of the pilot is totally based on the
aviation, weather things, not anything to do with the patient.
It is not always possible, but as much as possible, keep him
insulated from the patient information.
Mr. Costello. Very good. We may have a few other questions
that other Members have submitted that we will be submitting to
you in writing to answer. The Chair thanks all of you for
taking the time to be with us today to offer your perspective
and your suggestions on this important topic.
As I said in the beginning, the purpose of the hearing was
to have an opportunity for government and industry and the
health care community to discuss this important issue and to
try and figure out how we can enhance helicopter EMS safety,
and I think we have had a very good hearing today. We have
heard different perspectives and different viewpoints as to how
we get where we all need to be, and I assure you, Ms. Friedman
and others, that we are not going to stop here; that we are
going to work with Mr. Altmire, we are going to work with Mr.
Salazar and others concerning their legislation to see how we
can go from where we are today to enhancing EMS helicopter
safety.
So, again, we thank you for being here, for offering your
testimony. You may receive some written questions in the mail
from us to respond to, but that concludes our hearing. Thank
you.
[Whereupon, at 12:39 p.m., the Subcommittee was adjourned.]
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