Aviation Safety: Improved Data Collection Needed for Effective
Oversight of Air Ambulance Industry (21-FEB-07, GAO-07-353).
Air ambulance transport is widely regarded as improving the
chances of survival for trauma victims and other critical
patients. However, in recent years, the number of air ambulance
accidents has led to increased industry scrutiny by government
agencies, the public, the media, and the industry itself. The
Federal Aviation Administration (FAA), which provides safety
oversight, has been called upon by the National Transportation
Safety Board (NTSB) and others to issue more stringent safety
requirements for the industry. GAO's study addressed (1) recent
trends in the air ambulance industry, (2) FAA's challenges in
providing safety oversight, and (3) FAA's efforts to address the
challenges and what is known about the effects of these efforts.
To address these issues, we analyzed FAA, NTSB, and industry
data, interviewed federal and industry officials, and conducted
five site visits, among other things.
-------------------------Indexing Terms-------------------------
REPORTNUM: GAO-07-353
ACCNO: A66084
TITLE: Aviation Safety: Improved Data Collection Needed for
Effective Oversight of Air Ambulance Industry
DATE: 02/21/2007
SUBJECT: Air transportation
Aircraft accidents
Aircraft industry
Aircraft safety
Data collection
Emergency medical services
Federal regulations
Helicopters
Inspection
Performance measures
Risk assessment
Safety standards
Transportation industry
Transportation safety
Government agency oversight
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GAO-07-353
* [1]Results in Brief
* [2]Background
* [3]Air Ambulance Operations Perform Various Duties and Take Sev
* [4]Government and Industry Both Play a Role in Air Ambulance Ov
* [5]Increase in Size and Safety-Related Concerns Mark Industry's
* [6]Data Limitations Preclude Complete Understanding of Industry
* [7]Growth Is Primarily in Stand-Alone Businesses and Has Led to
* [8]Increase in Number of Accidents Has Led to Greater Industry
* [9]FAA Safety Oversight Does Not Fully Address Industry's Opera
* [10]Air Ambulance Operations Face Risks Different from Those Fac
* [11]FAA Inspections Framework Is Not Tailored to Risks of the Ai
* [12]Part 135 Regulations Do Not Address Specific Dangers Inheren
* [13]FAA Efforts to Improve Safety Are Under Way, but Effects Are
* [14]FAA Efforts Targeted at Improving Air Ambulance Safety Overs
* [15]FAA Guidance Focuses on Identified Safety Concerns
* [16]Additional FAA Resources Allocated to Air Ambulance
Oversigh
* [17]FAA Has Increased Collaboration with the Industry
* [18]FAA Lacks an Approach for Evaluating the Effects of Its Effo
* [19]Conclusions
* [20]Recommendations for Executive Action
* [21]Agency Comments and Our Evaluation
* [22]GAO Contact
* [23]Staff Acknowledgments
* [24]GAO's Mission
* [25]Obtaining Copies of GAO Reports and Testimony
* [26]Order by Mail or Phone
* [27]To Report Fraud, Waste, and Abuse in Federal Programs
* [28]Congressional Relations
* [29]Public Affairs
Report to the Chairman, Subcommittee on Aviation, Committee on
Transportation and Infrastructure, House of Representatives
United States Government Accountability Office
GAO
February 2007
AVIATION SAFETY
Improved Data Collection Needed for Effective Oversight of Air Ambulance
Industry
GAO-07-353
Contents
Letter 1
Results in Brief 3
Background 5
Increase in Size and Safety-Related Concerns Mark Industry's Recent Years
13
FAA Safety Oversight Does Not Fully Address Industry's Operational Risks
23
FAA Efforts to Improve Safety Are Under Way, but Effects Are Not Being
Measured 33
Conclusions 40
Recommendations for Executive Action 41
Agency Comments and Our Evaluation 41
Appendix I Scope and Methodology 43
Appendix II NTSB Air Ambulance Accident Data 48
Appendix III Comments from the Association of Air Medical Services 55
Appendix IV GAO Contact and Staff Acknowledgments 61
Tables
Table 1: Examples of Independent and Hospital-Based Operators 9
Table 2: Examples of Air Ambulance Industry Initiatives to Address Safety
Concerns 22
Table 3: Key FAA Published Efforts to Improve Air Ambulance Safety 34
Table 4: NTSB Recommendations and FAA Responses 38
Table 5: Industry and Trade Organizations Interviewed 43
Table 6: Description of States Selected for Site Visits 46
Table 7: NTSB Air Ambulance Accident Information, 1998 through 2005 48
Figures
Figure 1: Air Ambulance Helicopter 2
Figure 2: Helicopter Air Ambulance Service Locations 7
Figure 3: Air Ambulance Scene Response Flight Legs 11
Figure 4: Annual Air Ambulance Bases and Aircraft, 2003 to 2005 15
Figure 5: Number of Hospital-Based and Airport and Helipad Air Ambulance
Bases, 2003 to 2005 18
Figure 6: Total Air Ambulance Accidents, 1998 to 2005 21
Figure 7: Time of Day of Air Ambulance Fatal and Nonfatal Accidents, 1998
to 2005 25
Figure 8: Percentage of Air Ambulance and Other Helicopter Accidents
Associated with Adverse Weather, 1998 to 2005 26
Abbreviations
AAMS Association of Air Medical Services AMPA Air Medical Physician
Association AMSAC Air Medical Safety Advisory Council CAMTS Commission on
the Accreditation of Medical Transport Systems CUBRC Calspan-University of
Buffalo Research Center DOT Department of Transportation FAA Federal
Aviation Administration FARE Foundation for Air Medical Research and
Education GAATAA General Aviation and Air Taxi Activity and Avionics
survey HEMS Helicopter Emergency Medical Services NTSB National
Transportation Safety Board PHI Petroleum Helicopters International SEP
Surveillance and Evaluation Program
This is a work of the U.S. government and is not subject to copyright
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separately.
United States Government Accountability Office
Washington, DC 20548
February 21, 2007
The Honorable Jerry F. Costello
Chairman
Subcommittee on Aviation
Committee on Transportation and Infrastructure
House of Representatives
Dear Mr. Chairman:
The image of a helicopter air ambulance landing at a hospital or on the
side of a highway--a familiar sight on television news--is an indication
of the degree to which such ambulances are now a part of the nation's
medical system. Air ambulance transportation is widely regarded as having
a beneficial impact on improving the chances of survival and recovery for
trauma victims and other critical patients, particularly in rural areas
that lack readily accessible advanced-care facilities and medical
specialists. Medical theory and practice hold that providing critically
injured patients with surgical intervention within the first hour after
injury occurs--a time period referred to by some as the "golden hour"
--can significantly improve chances for survival and recovery. Air
ambulance helicopters, with their ability to land at accident sites and
quickly shuttle to landing areas at or near hospitals, can reduce
transport times for many patients. The image of a helicopter air ambulance
landing at a hospital or on the side of a highway--a familiar sight on
television news--is an indication of the degree to which such ambulances
are now a part of the nation's medical system. Air ambulance
transportation is widely regarded as having a beneficial impact on
improving the chances of survival and recovery for trauma victims and
other critical patients, particularly in rural areas that lack readily
accessible advanced-care facilities and medical specialists. Medical
theory and practice hold that providing critically injured patients with
surgical intervention within the first hour after injury occurs--a time
period referred to by some as the "golden hour" --can significantly
improve chances for survival and recovery. Air ambulance helicopters, with
their ability to land at accident sites and quickly shuttle to landing
areas at or near hospitals, can reduce transport times for many patients.
Figure 1: Air Ambulance Helicopter
Air ambulance operations, however, can also be risky. Challenging flight
conditions such as flying at night and into unfamiliar landing sites,
within the critical window for medical intervention, makes these flights
inherently more risky than those conducted by other helicopters. In recent
years, the number of air ambulance accidents has led to increased scrutiny
of the industry by government agencies, the public, the media, and the
industry itself. In addition, the Federal Aviation Administration (FAA),
the federal agency responsible for providing safety oversight, has been
asked by the National Transportation Safety Board (NTSB) and others to
issue more stringent safety requirements for the industry.
In response to your request, we examined the safety issues facing the
industry and FAA's safety oversight. Specifically, we addressed the
following questions: (1) What have been the recent trends in the air
ambulance industry with regard to size, composition, and safety record?
(2) What challenges does FAA face in providing safety oversight of the air
ambulance industry? and (3) What efforts does FAA have under way to
address any oversight challenges, and what is known about the effects of
these efforts? To address these questions, we analyzed NTSB, FAA, and
industry data; conducted an extensive literature review; and interviewed
FAA and NTSB officials, as well as industry experts and representatives
from key industry associations and air ambulance operators. In addition,
we conducted site visits to five states that had multiple air ambulance
operators with a diversity of business models operating in proximity to
one another. During these site visits, we interviewed representatives of
air ambulance service providers and officials from local FAA flight
standards district offices. We also visited operator facilities and
observed a number of elements of operations. This report focuses on the
aviation safety aspects of commercial helicopter air ambulances; the scope
of our study did not include analysis of the appropriateness of associated
costs, payments, or medical utilization of air ambulance transportation.
We conducted our review from April 2006 through January 2007 in accordance
with generally accepted government auditing standards. More details
regarding our scope and methodology can be found in appendix I.
Results in Brief
The air ambulance industry has experienced recent growth, primarily in
stand-alone (independent) operations, and an increase in the number of
accidents, resulting in increased efforts to make safety-related
improvements. There is limited or incomplete data available on basic
aspects of the industry, including the number of air ambulance helicopters
and the number of hours flown by air ambulances. Although data limitations
preclude a complete understanding of the industry, including its growth,
available data for 2003 to 2005 show the number of helicopters involved
exclusively in air ambulance operations increased 38 percent (from 545 to
753), while the number of locations from which they operate grew by 30
percent (from 472 to 614). Similarly, although data are not available on
the number of stand-alone and hospital-based operators, most of the growth
in operating locations since 2003 has been in airports and stand-alone
helipads rather than hospital-based locations. This is a strong indication
of the movement toward stand-alone operations. Industry sources indicate
that this growth has produced more competition in certain areas and
potentially led to such unsafe practices as "helicopter shopping"--a
continued search for air ambulance service by emergency medical service
dispatchers until an operator agrees to accept a flight. We identified a
total of 89 air ambulance accidents from 1998 to 2005 that resulted in 75
fatalities and 31 serious injuries. These 89 accidents represent nearly 40
percent of the total air ambulance accidents since 1972. The annual number
of accidents involving air ambulances tripled from 6 to 18 from 1998 to
2003 but has since declined to 12 and 11 in 2004 and 2005, respectively.
This number remains above the levels of the 1980s, but the drop in the
past two years may reflect increased safety efforts by the industry. These
efforts include the creation of a study group that recommends practices
for operators to follow and the implementation of various training
programs. However, the lack of data about the number of flights or flight
hours precludes the calculation of the industry's accident rate, making it
difficult to determine whether the industry is becoming more or less safe.
FAA's main challenge in providing safety oversight for air ambulances is
that its oversight approach is not geared toward air ambulance helicopter
operations, but rather to other segments of the aviation industry that do
not share many of the same operating characteristics and risks. To oversee
air ambulance operations, FAA uses a set of regulations--Part 135--that it
also uses to oversee air taxi services and other on-demand operations.
Unlike these other operators, air ambulances provide urgent medical
transport often by flying to remote scenes, landing at ad-hoc prepared
sites, and operating at all times of day in a variety of weather
conditions. Further, air ambulance transport can involve emergency medical
service dispatchers, crew members, and others, underscoring the role of
human factors before and during a transport. Available data confirm that
air ambulance accidents are often related to their unique operating
environment. For example, fatal crashes involving air ambulances occur
most often at night, and air ambulance helicopters are four times more
likely to have weather-related crashes than helicopters used by other
operators flying under the same set of regulations. Our work showed that
FAA inspectors may not have the necessary expertise to certify some safety
technology for implementation by air ambulance operators. Inspectors also
have limited opportunities to review the air ambulance operations at the
many remote base stations of large operators due to a lack of time and
resources. The broad nature of Part 135 regulations further inhibits FAA
safety oversight, as requirements within these regulations may not fully
address the risks inherent to air ambulance operations.
FAA has a number of efforts under way to strengthen its oversight of air
ambulance operators, but it has not developed ways to evaluate the
effectiveness of these efforts. FAA's efforts include establishing a task
force to review air ambulance accidents, conducting various meetings with
industry officials, and devoting additional staff resources to overseeing
the largest operators. Another effort involves issuing guidance to FAA
inspectors and air ambulance operators to enhance air ambulance safety.
This new guidance has covered such matters as reviewing pilots' and
mechanics' adherence to procedures, promoting risk management, and
emphasizing certain aspects of safety. Although the guidance has been
voluntary to date, FAA has not ruled out future regulatory action. While
FAA inspectors are required to promote the safety actions outlined in the
guidance to air ambulance operators, FAA has no plans for tracking the
degree to which operators are voluntarily implementing the guidance. FAA's
ability to assess its efforts is limited not only because it does not know
the extent of operators' implementation of the guidance but also because
it cannot accurately measure basic trends in the industry, such as changes
in the accident rate. Measuring these trends requires reliable data about
actual flight hours--data FAA does not currently have. Without this data,
FAA cannot know if it is targeting the appropriate amount of agency
resources to air ambulance oversight or whether its efforts are achieving
their intended results. Our discussions with air ambulance operators
indicated that flight-hour information is available and that operators are
willing to share it with FAA.
To help FAA monitor industry growth trends, accident rates, and operator
implementation of FAA guidance, we are recommending that the Secretary of
Transportation direct the Administrator of FAA to (1) identify the data
necessary to better understand the air ambulance industry and develop a
systematic approach for gathering and using this data, and (2) collect
information to evaluate the effectiveness of voluntary FAA guidance. We
provided the Department of Transportation (DOT) and NTSB with a draft copy
of this report for their review and comment. DOT agreed with our findings
and conclusions, and agreed to consider our recommendations. NTSB agreed
with our findings, conclusions, and recommendations. Both agencies
provided technical comments, which were incorporated, as appropriate. We
also provided the Association of Air Medical Services (AAMS) with a draft
of this report to review, and AAMS agreed with our recommendations.
Background
Air Ambulance Operations Perform Various Duties and Take Several Forms
Air ambulance use in the United States began on a small scale in the early
1970s, after use of air evacuation for wounded troops was demonstrated to
be an effective means of reducing combat mortality both in the Korean and
Vietnam wars. Air ambulances currently perform a number of functions.
Although most people may associate an air ambulance with an on-scene
response to an accident, the majority of transports--about 54 percent--are
from hospital to hospital. On-scene responses make up another 33 percent,
and the remaining 13 percent of transports include organ, medical supply,
and specialty medical team transports. Air ambulances are of two main
types--helicopters and fixed-wing aircraft. These two types of aircraft
are generally used on different types of missions, with helicopters
providing on-scene responses and much of the shorter distance
hospital-to-hospital transport, and fixed-wing aircraft providing longer
hospital-to-hospital transports between airports. Helicopter air
ambulances make up more than 80 percent of the air ambulance fleet and,
unlike fixed-wing aircraft, do not always operate under the direction of
FAA air traffic controllers. This report concentrates on safety oversight
issues related to helicopter air ambulances.
Air ambulances are an integrated part of emergency medical systems
throughout the United States, and the market is dominated by a few large
operators. For example, it has been estimated that the top seven operators
operate nearly 80 percent of helicopter air ambulances. Before commencing
air ambulance flights, an operating certificate must be obtained from
FAA.^1 FAA issues the certificate after determining that an operator's
manuals, aircraft, facilities, and personnel meet federal safety
standards. FAA subsequently monitors the operator, primarily through
safety inspections, to ensure that an operator continues to meet the terms
of its certificate. Air ambulance operators often operate multiple air
ambulance programs from a variety of satellite base stations at hospitals,
airports, or helipads in other locations.^2 Figure 2 shows base locations
of helicopter air ambulance services that perform on-scene transports.
^1Such direct air carriers must also obtain an exemption from the
Department of Transportation's economic regulatory authority, which is
provided under 14 CFR Part 298.
^2For the purposes of this report, the use of the term "operator" refers
to the FAA certificate holder.
Figure 2: Helicopter Air Ambulance Service Locations
Air ambulance operations can take many different forms but are generally
one of two types--hospital-based or stand-alone:^3
o In a hospital-based model, a hospital typically provides the
medical services and staff and contracts with an aviation services
provider for pilots, mechanics, and aircraft. The aviation
services provider also holds the FAA operating certificate. In the
hospital-based model, the hospital is responsible for billing the
patient and pays the operator on a fixed monthly and variable
hourly rate for services provided.^4
o In a stand-alone (independent) provider model, an independent
operator sets up a base in a community and serves various
facilities and localities. Typically, the operator holds the FAA
operating certificate and employs both the medical and flight
crews, or contracts with an aviation services provider for all of
these things. Compared with the hospital-based model, this
approach carries more financial risk for the operator because
revenues depend solely on patient flights.
Table 1 illustrates the differences in these business models by
providing information on two of the operators we visited.
Table 1: Examples of Independent and Hospital-Based Operators
Characteristic Independent operator Hospital-based operator
Program Petroleum Helicopters Teddy Bear Transport
International Air Medical
Cook Children's Medical
Center
Holder and location Petroleum Helicopters CJ Systems; Harrisburg,
of FAA operating International (PHI); Pennsylvania
certificate Lafayette, Louisiana
Number of bases 49 1
Location of bases 14 states Fort Worth, Texas
Number of 224 1
helicopters
Tax status For profit Nonprofit
Flight crew employer PHI CJ Systems
Medical crew PHI Cook Children's Medical
employer Center
Revenue sources Per-flight basis Patient flights,
hospital admission
Mission profile 50% on-scene 50% 100%
hospital-to-hospital hospital-to-hospital
Source: GAO.
Government and Industry Both Play a Role in Air Ambulance
Oversight
All levels of the government and the air ambulance industry play
significant roles in air ambulance oversight. FAA has oversight
over commercial aviation activities performed by air carrier
operators, a group that includes operators of air ambulances.
FAA's air ambulance safety oversight is carried out by inspectors
located in FAA field offices throughout the United States that are
a part of nine regional offices. For each operating certificate,
FAA puts together a team of inspectors (also known as the
certificate management team), led by principal inspectors, who
focus on one of three disciplines: avionics, maintenance, or
operations. Since 1985, FAA has used the National Flight Standards
Work Program Guidelines, its traditional inspection program for
airlines, as a primary means of ensuring air ambulance operator
compliance with safety regulations. Under the National Flight
Standards Work Program Guidelines, an FAA committee identifies an
annual minimum set of required inspections that are to be
undertaken. In addition, inspectors determine annual sets of
planned inspections based on their knowledge and experience with
the particular operator they oversee. When violations of statutory
and regulatory requirements are identified through inspections,
FAA has a variety of enforcement tools that it may use to respond
to the violations, including administrative and legal sanctions.
Under FAA regulation, most air ambulances operate under rules
specified in Part 135 of Title 14 of the Code of Federal
Regulations.^5 However, pilots may operate under different
standards, depending on whether they are carrying patients.
Without patients or passengers on board, pilots may operate under
rules specified in Part 91 of Title 14.^6 These flights are
considered "positioning" flights and occur when flying to an
accident scene or after having transported the patient to the
hospital or other destination. Medical personnel are often on
board for these flights, as they are considered part of the crew
rather than passengers. With patients on board, pilots are
required to operate under Part 135 rules.
Part 91 and Part 135 flight rules differ significantly in two key
areas--(1) weather and visibility minimums and (2) rest
requirements--with Part 135 requirements being more stringent.
Under Part 91, the basic weather minimum requirements for visual
flight rules only state that helicopters operate "clear of clouds"
if flying under 1,200 feet in uncontrolled (Class G) airspace and
that the pilot must have "adequate opportunity to see any air
traffic or obstruction in time to avoid a collision." This does
not impose any specific flight visibility distance on the pilot.
In contrast, Part 135 requires that helicopter operators flying
under 1,200 feet have visibility of at least a half mile during
the day and at least one mile at night. This is the only situation
in which Part 91 weather minimums for visual flight rules are
lower than Part 135. Additionally, Part 135 requires that all
helicopter operators have visual surface reference during the day
and visual surface light reference at night. The other key
difference between Part 91 and Part 135 is the imposition of rest
requirements on pilots. Part 91 neither contains requirements for
pilots to rest prior to their flights nor prescribes a maximum
duty time. Part 135, on the other hand, requires helicopter pilots
conducting emergency medical operations to have adequate rest
periods before and after their flights, and it also contains
restrictions on the number of consecutive hours that pilots may
fly.^7
In many air ambulance trips, part of the trip may involve Part 135
rules, while another part may involve Part 91 rules. Scene
response missions for air ambulance helicopters frequently have
three legs: the flight en route to the accident scene, the
transport of the patient to the hospital, and the repositioning of
the helicopter back to its base (see fig. 3). Of these three
flight legs, only the leg during which patients or other
passengers (medical crew are not considered passengers) are on
board must be flown under Part 135 flight rules. Because air
ambulance flights without patients or passengers could be flown
under Part 91 requirements, there may be more than twice as many
flights taking place under Part 91 compared with Part 135.
Figure 3: Air Ambulance Scene Response Flight Legs
NTSB also plays a role in monitoring the safety issues related to
the air ambulance industry. As an independent federal agency
charged by Congress with investigating every aviation accident in
the United States, NTSB conducts investigations of air ambulance
accidents and develops factual reports containing determinations
of probable cause for these accidents. In January 2006, NTSB
published a special report focusing on emergency air medical
operations, which included an identification of recurring safety
issues in air ambulance accidents and subsequent recommendations
for improving safety in the industry.^8 Additionally, in 1988, in
response to an increased number of accidents in the mid-1980s,
NTSB published a safety study that examined similar issues. The
study contained 19 safety recommendations to FAA and others, which
have since been addressed, according to NTSB.^9
Some state and local governments play a role in oversight of the
air ambulance industry, as well. The federal Airline Deregulation
Act of 1978 explicitly prohibits states from regulating the price,
route, or service of an air carrier; therefore, oversight at the
state or local levels is generally limited to the medical care and
equipment of air ambulance services. The extent of this oversight,
however, varies by state and locality. Some states have not
developed a regulatory framework to oversee the medical care side
of air ambulance services. Other states do provide some oversight;
California, for example, delegates authority to local governments
for emergency medical service coordination and requires air
ambulance providers to obtain a permit from any county in which
they routinely operate, irrespective of where the provider is
based. Still others, such as Maryland, Texas, Washington, and
Arizona, require state licensure of all air ambulance service
providers.
The industry also plays a role in its own oversight. One such
industry-driven activity is the accreditation offered by the
Commission on Accreditation of Medical Transport Systems (CAMTS),
a 16-member organization that provides voluntary accreditation for
medical transport systems, including air ambulances. Over 120 air
ambulance providers have earned CAMTS accreditation since its
inception in 1991, and five states have made CAMTS accreditation
mandatory for all air ambulance providers wishing to operate
within their jurisdiction. CAMTS places an overarching emphasis on
patient care and transport safety, with specific accreditation
standards focusing on aircraft maintenance and use as well as the
medical, communications, and management aspects of operation.
Industry trade groups also play an informal role in oversight.
Industry groups, including the Association of Air Medical
Services, Helicopter Association International, the Air Medical
Physician's Association, and the National EMS Pilots Association,
devote much of their attention to information sharing regarding
operational challenges and best practices within the industry,
organizing conferences, and publishing white papers in order to
place a continued emphasis on safety.
Increase in Size and Safety-Related Concerns Mark Industry�s
Recent Years
Since 1998, the air ambulance industry has been characterized by
growth, an increased number of accidents, and various efforts to
make operations safer. Growth, according to industry officials and
the limited data available, has occurred mainly in stand-alone
for-profit operations rather than nonprofit hospital-based
programs. For much of this expansion period, the number of
accidents also rose, peaking at 18 in 2003. During the 8-year
period we examined (1998 through 2005), 89 air ambulance accidents
occurred, but a lack of data about the number of flights or hours
flown prohibits us from calculating whether the rate of accidents
has increased, decreased, or remained the same over this period.
The 89 accidents represent nearly 40 percent of all air ambulance
industry accidents since 1972. Thirty-one of these accidents
resulted in fatalities, and 9 others resulted in serious injuries
to people on board. To address these developments, the air
ambulance industry has been encouraging greater safety among its
operators through such steps as conferences, additional training,
and safety awareness programs.
Data Limitations Preclude Complete Understanding of Industry�s
Growth
Although industry experts and observers acknowledge the recent
growth of the air ambulance industry, the available data make it
difficult to gauge clearly the extent of the growth. Several years
of data on two indicators--number of aircraft and number of
operating locations--are available in a database maintained by the
Calspan-University of Buffalo Research Center (CUBRC) in alliance
with AAMS.^10 For 2003, the first year of the database,
association members reported a total of 545 helicopters stationed
at 472 bases (airports, hospitals, and helipads).^11 By 2005, the
number of helicopters listed in the database had grown to 753, an
increase of 38 percent, and the number of bases had grown to 614,
an increase of 30 percent (see fig. 4). A database official said
that to some degree, the increase reflects a broadening of the
criteria for inclusion as well as better reporting since the
database was first established, but the increase also reflected
actual growth, which is similar to anecdotal information relayed
to us by air ambulance operators. For example, officials from two
large operators told us that their companies had added bases or
aircraft in the last few years. FAA maintains records of the
number of air ambulance operator aircraft currently in operation
but does not distinguish a company's dedicated air medical
aircraft from its other aircraft. FAA does estimate the number of
air medical aircraft based on its annual General Aviation and Air
Taxi Activity and Avionics (GAATAA) survey, and according to
available estimates, there were 435 air medical helicopters in
1999 and 741 in 2004, an increase of 70 percent.^12 It is
difficult to regard these estimates as reliable, however, because
the survey is based on a sample of aircraft owners and has
historically experienced low response rates.
Figure 4: Annual Air Ambulance Bases and Aircraft, 2003 to 2005
Data are less available on whether this increase in aircraft
translates into an increased number of operating hours. FAA does
not collect flight-hour data from air ambulance operators. Unlike
scheduled air carriers, which are required to report flight hours,
air ambulance operators and other types of on-demand operations
regulated under Part 135 are not required to report flight
activity data to FAA or DOT.^13 FAA does develop estimates of
these flight hours, using responses to its annual GAATAA survey.
FAA estimated that air ambulances amassed about 900,000 flight
hours annually from 1999 to 2003 and that the number of flight
hours increased to 1.6 million in 2004. However, as noted, the
reliability of these estimates is questionable, given various
shortcomings with the GAATAA survey.^14 Other studies have shown
flight-hour estimates that are much lower than FAA estimates. For
example, a study sponsored by the Air Medical Physician
Association (AMPA) has also estimated annual flight hours for the
air medical industry. To determine flight hours, the study's
authors posted a survey on the Flightweb listserve and surveyed
five of the largest air medical operators--as well as information
listed in the AAMS membership directory and the Directory of Air
Medical Programs, published in AirMed--to determine the number of
programs and helicopters.^15 To determine the number of flight
hours, the authors multiplied the average flight hours per program
by the total number of programs identified in each year. As a
result, the AMPA study estimated that the total number of air
medical flight hours grew from 187,216 in 1998 to 217,584 in 2001,
an increase of 16 percent. FAA estimates were considerably higher
for this period. For example, for 2001, FAA estimated a total of 1
million air medical flight hours.
Some other operations-related indicators are available, and they
point to an increase in activity. The 2002 AMPA study also
estimated that the total number of patients flown in air
ambulances rose from 174,501 in 1998 to 203,772 in 2001, an
increase of 17 percent. The study's authors obtained these
estimates by multiplying the number of air medical programs by the
average number of patients transported each year. Data maintained
by the Department of Health and Human Services' Centers for
Medicare and Medicaid Services indicate that the number of air
ambulance trips reimbursed by Medicare increased 24 percent, from
1.65 transports per 1,000 beneficiaries in 2001 to 2.04 transports
per 1,000 beneficiaries in 2004. Finally, two recent studies by
government agencies, including the Congressional Research Service
and FAA, acknowledged the industry's growth.^16 However, these
studies, like our own, did not find a fully comprehensive
indicator of this growth.
One other potential indicator of growth is the number of air
ambulance operators, but we were unable to find data showing the
change in operators over a several-year period. FAA maintains
information about the air ambulance operators it oversees, but
only on those currently in operation. As such, there was no way to
determine how the number of operators had changed over time. FAA
data indicate that as of July 31, 2006, there were a total of 76
air ambulance operators. The number of operators is considerably
lower than the number of aircraft and bases. This is because some
operators have large fleets of aircraft and operate from many
bases. For example, Air Methods, the largest air medical operator,
operates 208 helicopters out of 96 bases. Government and industry
officials and operators we spoke with indicated that industry
consolidation was the current trend.
Growth Is Primarily in Stand-Alone Businesses and Has Led to
Increased Competition in Some Locales
We did not find any data on the distribution of business models
within the air ambulance industry, but the consensus that emerged
from the industry officials we spoke with and the information we
reviewed was that growth has occurred mainly in the stand-alone
(independent) provider business model. For example, a 2006 public
policy paper by the Foundation for Air Medical Research &
Education (FARE)^17 observed that many air medical services "had
become independent, community based resources." Similarly, an FAA
research paper published in September 2005 noted that "the fastest
growing segment of the [air medical] industry is the independent
provider." In our interviews with government and industry
officials, there was general agreement that the independent
provider model has grown more than the traditional hospital-based
model.
Additional support for this view can be seen in the types of
operating bases that are growing most rapidly--airport and helipad
bases, which are the typical bases of stand-alone operators.
According to the Atlas and Database of Air Medical Services, the
total number of stand-alone bases increased more than hospital
bases from 2003 to 2005 (see fig. 5). In 2003, the number of bases
reported by AAMS members was about equally divided between
hospital bases and airport and helipad bases. By 2005, the number
of hospital bases had increased by 6 percent (from 234 to 249),
while the number of airport and helipad bases had increased by 53
percent (from 238 to 365).
Figure 5: Number of Hospital-Based and Airport and Helipad Air
Ambulance Bases, 2003 to 2005
The growth in the stand-alone business model has been influenced
by the potential for profit making, according to the officials we
interviewed and others who have studied the industry. The
influencing factor they most often cited was the 1997 mandate for
the development of a Medicare fee schedule for ambulance
transports.^18 Officials we spoke with and literature we reviewed
cited the implementation of the fee schedule as a factor in the
increase in stand-alone services. The fee schedule was implemented
gradually starting in 2002, and since January 2006, 100 percent of
payments for air ambulance services have been made under the fee
schedule. Prior to 2002, all ambulance service reimbursements by
Medicare were based on the type of provider. Hospital-based
providers were reimbursed based on their reasonable costs, while
independent providers were reimbursed based on reasonable charges.
These payment patterns resulted in wide variation in payment rates
for the same service. In its final rule on the fee schedule
published in the Federal Register on February 27, 2002, the
Centers for Medicare and Medicaid Services anticipated that the
fee schedule would redistribute income from ground to air
ambulance services and from hospital-based to independent
operators.
This potential for higher and more certain revenues has, in the
opinion of many of our sources, increased competition in certain
areas. The Phoenix and Dallas/Fort Worth areas were cited as
examples of locales where the presence of a large number of air
ambulance operators intensifies competition. One industry official
wrote that there were more air medical helicopters in Phoenix than
in all of Canada.^19 Another noted that the Dallas/Fort Worth area
had been home to only one operator for many years, but by mid-2006
it had eight air ambulance operators.
Increased competition, according to industry experts, can also
bring potentially unsafe practices. Although we were unable to
determine how widespread these activities are, experts cited the
potential for such practices, including the following:
o Helicopter shopping: FAA defines this as the practice of
calling, in sequence, various operators until an operator agrees
to take a flight assignment, without sharing with subsequent
operators the reasons the flight was declined by previously called
operators. This practice can lead to an unsafe condition in which
an operator initiates a flight that it may have declined if it had
been aware of all of the facts surrounding the assignment.^20 For
example, in July 2004, a medical helicopter collided with trees
shortly after takeoff, killing the pilot, flight nurse, flight
paramedic, and patient. Three other air ambulance operators had
previously turned down this same flight, including one who had
attempted it but was forced to return due to fog. The pilot during
the accident, however, was not informed by emergency medical
service dispatchers that other pilots had declined the flight due
to the weather conditions. According to NTSB, inadequate dispatch
information contributed to the accident.
o Call jumping: Industry officials reported that call jumping
occurs when an air ambulance operator responds to a scene to which
that operator was not dispatched or when multiple operators are
summoned to an accident scene. This situation is potentially
dangerous because the aircraft are all operating in the same
uncontrolled airspace--often during nighttime or in marginal
weather conditions--increasing the risk of a midair collision or
other accident. The term "call jumping" originated in the 1970s
when some ground ambulance services were involved in a similar
practice.
o Inappropriate use of air medical aircraft: One industry official
has posited that air medical helicopter use may be excessive,
unsafe, and not beneficial for most patients, citing recent
studies that conclude few air transport patients benefited
significantly over patients transported by ground and the recent
increase in the number of air medical accidents. Other studies
have disagreed with this position, citing air ambulances' impact
on reductions in mortality by quickly transporting critically
injured patients.
Increase in Number of Accidents Has Led to Greater Industry Focus
on Safety-Related Activities
From 1998 through 2005, the air ambulance industry averaged 11
accidents per year, according to NTSB data.^21 The annual number
of air ambulance accidents increased from 6 in 1998 to a high of
18 in 2003, then receded to 12 in 2004 and 11 in 2005 (see fig.
6). Of the 89 total accidents from 1998 to 2005, 31 accidents
resulted in the deaths of 75 people.^22 Another nine accidents
resulted in serious injuries to passengers or crew. In 2003, the
peak year for accidents in our review period, there were 4
accidents with fatalities and 1 with serious injuries. The
remaining 2003 accidents had either minor injuries (4) or no
injuries (9).
Figure 6: Total Air Ambulance Accidents, 1998 to 2005
The drop in the number of accidents in 2004 and 2005 came as the
industry undertook a series of steps designed to increase safety
awareness, discussed in further detail below. While this drop is a
favorable development relative to the number of accidents in 2003,
the numbers of accidents in 2004 and 2005 still closely match the
overall average for the period. In addition, the annual average of
11 accidents for the 8-year period is higher than in previous
years. Given the apparent growth in the industry, an increase in
the number of accidents may not indicate that the industry has, on
the whole, a poorer safety record during our review period than in
previous years. More specifically, without actual data on the
number of hours flown (data that FAA does not gather at present
but attempts to estimate), no accident rate can be accurately
calculated, eliminating the possibility of determining whether the
industry is becoming safer or more dangerous.
The air ambulance industry's response to the higher number of
accidents has taken a variety of forms. These initiatives include
efforts aimed at flight-hour data collection, research into
accident causes, training, and sharing of recommended practices.
For example, in 2005, the Pilot Study Safety Group--with the
support of FARE--sponsored a Web-based survey of air medical
pilots in which pilots were asked about their primary safety
concerns and what equipment they need to fly more safely. As a
result of the survey, the study group is recommending (1) that a
gold standard for air medical operators be established that would
include annual crew resource management^23 training for all
personnel, (2) flight simulation training for all pilots that
includes motion and instrument meteorological conditions, and (3)
night vision aid or mission-oriented unaided night flight training
for all crew members. Table 2 highlights some of the other
industry initiatives we have identified. Although the impact of
these initiatives on reducing accidents has not been assessed, the
decrease in the annual number of industry accidents since 2003 may
be an indicator that the initiatives are having some effect. This
seemed to be the case in the mid-1980s when a reversal of the
increasing accident trend occurred after a combination of industry
and FAA efforts.
^3Other types of operations include services that are operated by
government entities or the military. For example, the Maryland State
Police Aviation Division has a comprehensive helicopter air ambulance
capability that covers the entire state, while the California Highway
Patrol provides air ambulance services in portions of California. In
addition to these public-use operators, federally operated aircraft
provided by the U.S. Coast Guard and the U.S. Army conduct civilian air
ambulance operations in select states. It is estimated that 10 percent of
air ambulance operations in the United States are publicly operated. FAA
does not have direct safety oversight responsibilities for public-use and
military aircraft, and therefore, we did not include information on these
types of operations in this report.
^4A hospital, or other non airline entity, may hold an exemption from
DOT's economic authority to operate as an "indirect air carrier" (an
entity that does not actually operate aircraft) to sell air ambulance air
transport services directly to the public as a principal and, in turn,
contract with a properly licensed airline for the air transportation. A
blanket exemption authorizing such operations was issued in 1983 by the
Civil Aeronautics Board, DOT's predecessor. Such indirect air carriers may
not, however, mislead the public into thinking that they are airlines,
which has been emphasized to the industry through a letter from DOT's
Office of Aviation Enforcement to the Association of Air Medical Services.
^5Operating Requirements: Commuter and On Demand Operations and Rules
Governing Persons on Board Such Aircraft, 14 C.F.R. pt. 135 (2006).
^6General Operating and Flight Rules, 14 C.F.R. pt. 91 (2006).
^7According to FAA officials, while Part 91 repositioning flights are not
directly governed by Part 135 flight duty and rest requirements, there is
little, if any, negative effect.
^8National Transportation Safety Board, Special Investigative Report on
Emergency Medical Services Operations (Washington, D.C., 2006).
^9National Transportation Safety Board, Safety Study: Commercial Emergency
Medical Services Helicopter Operations (Washington, D.C., 1988).
^10AAMS is a nonprofit international association that serves providers of
air and surface medical transport systems.
^11The Atlas and Database of Air Medical Services is compiled by CUBRC's
Center for Transportation Injury Research in alliance with AAMS and the
air medical industry, with support from the Federal Highway Administration
and the National Highway Traffic Safety Administration. We did not
independently assess the accuracy of these data for the purposes of this
study. See appendix I for more information.
^12GAATAA is an annual survey of a sample of Part 135 on-demand and
general aviation operators. FAA uses the survey data to evaluate the
impact of safety initiatives and regulatory changes and for other
purposes.
^13NTSB has previously recommended FAA require activity reporting for all
Part 135 operators.
^14Based on the methodologies used, we recognize limitations with the
estimates of flight hours, and our presentation is for the purposes of
showing the wide range of estimates and the uncertainty associated with
these estimates. Therefore, we did not assess the reliability of FAA or
other estimates of flight hours for the purposes of this report.
^15Ira J. Blumen, M.D., and the University of Chicago Aeromedical Network,
A Safety Review and Risk Assessment in Air Medical Transport: Supplement
to the Air Medical Physician Handbook (November 2002). The methodology
used in this study was updated in a follow-up study to include the nine
largest air ambulance operators in the United States. For more
information, see I.J. Blumen and D. Lees, "Air Medical Safety: Your First
Priority," Principles and Direction of Air Medical Transport (Salt Lake
City, Utah: Air Medical Physician Association, September 2006).
^16For more information, see Bart Elias, Congressional Research Service,
The Safety of Air Ambulances (Washington, D.C., 2006); and Matthew J.
Rigsby, FAA, U.S. Civil Helicopter Emergency Medical Services Accident
Data Analysis, the FAA Perspective (September 2005).
^17FARE's mission is to support the charitable, educational and research
purposes of AAMS.
^18Balanced Budget Act of 1997, P.L. No. 105-33, S 4523 (Aug. 5, 1997).
^19Bryan E. Bledsoe, "Thank You for Not Flying," Air and Space Journal
(June/July 2006).
^20In 2006, FAA issued a letter to all state Emergency Medical Services
Directors (or equivalent positions) describing "helicopter shopping" and
requesting that the directors take action within their jurisdiction to
implement standards and procedures to prohibit this practice.
^21NTSB defines an aviation accident as "an occurrence associated with the
operation of an aircraft which takes place between the time any person
boards the aircraft with the intention of flight and all such persons have
disembarked, and in which any person suffers death or serious injury, or
in which the aircraft receives substantial damage." An accident was
included in the analysis as a helicopter air ambulance accident if (1) the
accident involved a helicopter being operated by an air medical transport
company and (2) the accident occurred during flight under either Part 91
or Part 135 regulations. All accidents involving public operators were
excluded from our analysis. See appendixes I and II for more information
about the accidents used in this analysis.
^22NTSB categorizes accidents by the highest level of injury sustained;
therefore, accidents in which fatalities occurred could also include
serious injuries, minor injuries, or no injuries.
Table 2: Examples of Air Ambulance Industry Initiatives to Address Safety
Concerns
Year Organization Initiative
1999 AAMS Distributed a safety poster to its
members and held "Safety Day" at the
Air Medical Transport Conference to
focus on program safety.
2000 Air Medical Safety Develops recommended practices for the
Advisory Council (AMSAC) industry.
2001/2002 AMSAC Implemented "Train the Trainer" Air
Medical Resource Management programs.
2002 Air Medical Physicians Published "A Safety Review and Risk
Association Assessment in Air Medical Transport."
2005 AAMS Adopted "Vision Zero," the air medical
community's program to promote safety
awareness.
2006 AAMS Sponsors the Flight Operational
Database for Air Medical Services--an
effort to collect flight and
flight-hour data for air medical
operators.
2006 Air & Surface Transport Published a position paper on transport
Nurses Association nurse safety in the transport
environment.
Source: GAO.
^23Crew resource management is the effective management of resources to
ensure that group members are operating from a common frame of reference
and toward a common goal of safety.
FAA Safety Oversight Does Not Fully Address Industry's Operational Risks
FAA resources, safety inspections, and regulations are tailored to oversee
a wide range of aviation activities and do not address many of the
operational risks facing air ambulance operators; therefore, FAA faces
challenges in providing safety oversight of the air ambulance industry.
Compared with other operators, air ambulance transports are subject to
greater risks, because these flights often occur during nighttime, in
adverse weather, and to remote sites in order to provide medical
attention. Operational control often occurs away from headquarters, and
many individuals and systems are involved in coordinating these flights,
underscoring the role of human judgment and risk-management protocols.
Available data demonstrate the risks inherent to the flight environment
and stemming from poor judgment. For example, NTSB data show that more
than one-third of all fatal air ambulance helicopter accidents involved
weather. FAA inspections and resources are not tailored to the air
ambulance industry, as few inspectors have the necessary qualifications to
certify operators' use of available safety technology, and inspections of
satellite bases by the assigned inspectors are infrequent. In addition,
the requirements within Part 135 regulations are broad and may not fully
address the dangers of poor decision making and the propensity for flights
to occur at night or to remote sites.
Air Ambulance Operations Face Risks Different from Those Faced by Other
Operations Subject to Part 135 Regulations
Under Part 135 rules, FAA regulates a wide variety of aviation operations,
including both "scheduled" (commuter flights with fewer than 10 seats) and
"nonscheduled" (on-demand air carriers, including air ambulances).^24 Part
135 operations can include such flights as small package cargo transport,
business and personal domestic and international transport, and shuttle
services to industrial job locations, such as oil platforms at sea. While
these operators may provide services in a variety of conditions, their
operations are generally characterized by smaller geographic operating
areas and more uniformity across their bases compared with that of air
ambulance operators. For example, these operators generally do not have
many remote bases and they take off and land at established landing zones.
Operationally, air ambulance operations are distinct from these other
types of operations in several key ways:
^24The FAA also applies specific limitations and requirements for Part 135
operators through the use of operations specifications, which are
individually developed for each operator.
o Operations are subject to greater risks. Air ambulance
helicopters are used to quickly transport individuals requiring
urgent or emergency medical attention at all hours of the day, and
crews face greater risks from flying at night, in marginal weather
conditions, and to and from remote sites. In "scene work" (picking
up a sick or injured patient at an off-airport/heliport site), the
landing zone is a makeshift site to which the pilot has likely
never been. Such operations, coupled with low visibility, can
contribute to severe outcomes. Available data tend to confirm that
the air ambulance transports face greater risks than other types
of helicopter transports. NTSB data of helicopter accidents
occurring between 1998 and 2005 show that factors related to
flight environment (such as light, weather, and terrain) underlie
70 percent of all air ambulance accidents, compared with 40
percent of accidents for other helicopter accidents.^25 Data on
the flight environment of air ambulance accidents indicate a
number of risks, including the following:
o Nighttime operations. Nighttime accidents for air
ambulance helicopters were more prevalent than for
other helicopter operations, and air ambulance
accidents tended to be more severe when they occurred
at night than during the day. More than half of all
air ambulance helicopter accidents took place at
night, compared with 9 percent of non-air-ambulance
helicopter accidents. Nighttime accidents also carry
a greater tendency to be fatal. NTSB data indicate
that from 1998 to 2005, air ambulance accidents that
occurred at night were almost four times more likely
to result in fatalities than those occurring during
the day--51 percent versus 13 percent (see fig. 7).
Figure 7: Time of Day of Air Ambulance Fatal and Nonfatal
Accidents, 1998 to 2005
o Adverse weather. Air ambulance accidents were more
often associated with weather conditions compared
with other helicopter accidents. Weather conditions
such as snow, gusting wind, and fog have been known
to contribute to air ambulance accidents. While 4
percent of other helicopter accidents are associated
with bad weather, air ambulance accidents were nearly
four times more likely (15 percent) to be attributed
to adverse weather (see fig. 8). NTSB data show that
overall, more than one-third of fatal air ambulance
accidents were attributable in part to weather.
Figure 8: Percentage of Air Ambulance and Other Helicopter
Accidents Associated with Adverse Weather, 1998 to 2005
o Remote sites. Flying to remote sites may further
expose the crew to other risks associated with
unfamiliar topography or ad-hoc landing sites. Data
show that accidents attributable to an in-flight
collision with objects occurred more frequently for
air ambulances than other helicopters. Air ambulance
helicopters also can encounter difficulties with
ad-hoc landing zones at remote sites, such as being
engulfed in clouds of dust commonly referred to as
brownouts. For example, in July 1998 during a
brownout, an air ambulance helicopter rolled over
when the pilot lost visual contact with the ground.
o Multiple bases located away from headquarters. FAA inspectors
assigned to large air ambulance certificates told us that the
dispersion of bases away from operator headquarters may result in
less disciplined adherence to internally established risk
assessment practices and protocols. Air ambulance bases are often
dispersed away from headquarters, either as independent
stand-alone bases or through contractual relationships with
hospitals. In contrast, other Part 135 helicopter operations
typically are not dispersed. The dispersion of bases away from the
certificate holders' headquarters and the location of bases are in
part due to medical need and demand for services. For example, one
state emergency medical services official reported that operators
look at high accident road intersections in considering where to
locate their bases.
o Many individuals and systems are involved in transports. Many
individuals and systems may be involved in coordinating air
ambulance transports. The number and expertise of people involved
in making decisions and passing on information about flights and
flight conditions can increase the risk of incorrect or incomplete
information being relayed. Multiple systems, involving both public
and private resources, are used in determining when to relay a
request, which air ambulance provider the request will be relayed
to, and if a request will be accepted and completed. Emergency
medical service dispatchers may not uniformly gather all of the
information needed by air ambulance providers, such as weather at
the landing site. Ground personnel may also be involved with
relaying critical information about the landing site to the crew;
but again, they may not provide critical information to the air
ambulance operator. For example, in Parumph, Nevada, an air
ambulance helicopter crashed while attempting to pick up a patient
at a remote site when ground personnel incorrectly informed the
helicopter crew that there were no wires obstructing the site.
o Human judgment may override risk-based protocols. Human judgment
can play a critical role in air ambulance transport, particularly
given the risks found in the flight environment and the medical
urgency. For example, during a dark night in June 1998 in La
Gloria, Texas, a helicopter crashed into trees nearly 20 miles
past the accident site to which it was headed. Attributes of the
crash, as reported by NTSB, indicated that the pilot failed to
recognize his intended destination and had flown past it and that
the adverse weather conditions resulted in the pilot's loss of
control from experiencing spatial disorientation. The pressure to
complete the airlift and the pilot's lack of experience with
flying by instruments were cited among the contributing factors by
NTSB in its accident report. The following accident data highlight
the prominence of poor human judgment in an already inherently
risky line of work:
o Ninety-four percent of air ambulance accidents
between 1998 and 2005 had at least one cause related
to pilot/operational errors, while 86 percent of
non-air-ambulance accidents during the same time
period had pilot/operational causes.
o In total, 28 percent of air ambulance accidents
between 1998 and 2005 had at least one planning or
decision-making related cause, while 19 percent of
non-air-ambulance accidents had such causes.
Air operators rely on a number of protocols, such as operational
control (the authority over initiating, conducting, and
terminating a flight), risk assessment matrices, and air medical
resource management training to help reduce the potential for poor
or erroneous judgment.^26 However, there are indications that in
air ambulance operations, these protocols may be inconsistently
implemented or followed. According to an FAA report that reviewed
air ambulance accidents occurring from 1998 to 2004, a lack of
operational control and poor aeronautical decision making were
significant contributing factors to these accidents.^27
Specifically, the report cited the susceptibility of crew members
to external factors in decision making. FAA inspectors we spoke
with reported that factors such as competition and the contractual
relationship between a vendor and provider can result in a loss of
operational control when unauthorized medical or other staff exert
pressure over the crew to fly. Several trade organizations also
said that the trend toward stand-alone providers has increased the
susceptibility of operational decision making to financial
incentives. Additionally, FAA inspectors we interviewed reported
that the dispersion of bases away from certificate holder
headquarters may result in less disciplined adherence to
internally established risk assessment practices and protocols.
FAA Inspections Framework Is Not Tailored to Risks of the Air
Ambulance Industry
FAA faces challenges in providing safety oversight to the air
ambulance industry because the existing inspections approach and
resources are not tailored to address the specific operational
aspects of air ambulance transports. Current FAA inspections and
resources may not enable its staff to meet the workload, training,
and travel requirements associated with conducting oversight
activities of air ambulance certificates. These challenges stem
from the distinctive way that air ambulance operators are
structured, their size, use of emerging technology, and dispersed
bases. In addition, FAA does not collect data that would help
demonstrate how its inspections approach is connected to safety
outcomes. These challenges are discussed in more detail below.
o Size and scope of air ambulance operations. Each year, the
National Flight Standards Work Program Guidelines sets the minimum
number of FAA required inspections for all Part 135 operators.
Although the National Flight Standards Work Program Guidelines
outlines the minimum inspection requirements for all Part 135
operators, the principal inspectors must determine how many
additional inspections might be necessary for adequate oversight
in light of the size and risk factors associated with a
certificate holder. In the case of large air ambulance operators,
these additional inspections can be considerable due to the size
and scope of the operations. For example, according to FAA
officials, the certificate management team for one large air
ambulance operator had 2,396 hours of required inspector
surveillance hours for fiscal year 2006. However, the team
estimates that a total of 4,425 inspector surveillance hours will
actually be needed for fiscal year 2006 in order to provide
appropriate oversight. Additionally, FAA's procedures for
establishing and maintaining pay grades for inspectors may be a
contributing factor in how much attention is given to the
oversight of large air ambulance operators. FAA assigns points to
the inspection activities of inspectors, and these points, in
turn, are tied to an inspector's pay. Several inspectors of air
ambulance operators reported that the points assigned to the
oversight of these operators are not commensurate with the risk
and size of these operations.
o Lack of training and qualifications to oversee use of
technology. According to FAA inspectors and officials we spoke
with, FAA has few inspectors who have the necessary qualifications
to certify the use of safety technology being adopted by air
ambulance operators, and FAA does not provide inspectors with
training in emerging safety technology. Several of the FAA
inspectors we interviewed reported not receiving what they felt to
be the necessary training that would allow them to provide
oversight of operators' implementation of new technology. This is
similar to concerns we raised in a previous report on FAA's
inspection program.^28 Specifically, we found that FAA develops
technical courses on an ad-hoc basis rather than part of an
overall curriculum for each inspector specialty--such as air
ambulance operations--because the agency has not systematically
identified the technical skills and competencies each type of
inspector needs to effectively perform inspections. FAA developed
the Flight Standards Inspector Resource Program, in which
inspectors with special expertise in a technology can assist other
inspectors whose operator may be using such technology. For
example, currently few inspectors are qualified to provide
operator certification in night vision goggle use. However,
several inspectors we spoke to found this program problematic,
because of the burden it poses to the inspector that must certify
the use of night vision goggles and continue to carry out their
other required duties.
o Limited oversight of base locations. While air ambulance bases
and helicopters for any one operator are often located across the
country, the assigned principal inspectors are based in the FAA
district office where the operating certificate is registered and
held by an operator's headquarters office. This may be important
because operators may have many remote bases of operations; for
example, one of the largest air ambulance companies has no
helicopters located at the headquarters location. FAA principal
inspectors assigned to large air ambulance certificates we spoke
with said they did not have the travel funds or time to perform
inspections of many remote bases. Instead, inspectors from local
FAA offices--called geographic inspectors--assist with the
oversight of these bases at the request of a principal
inspector.^29 Some FAA principal inspectors expressed little
confidence in the quality of these inspections, however, because
geographic inspectors may lack comprehensive knowledge of the
operators' manuals or lack helicopter expertise.
The challenges that FAA faces in applying its general inspections
approach to the air ambulance industry are also evident in its
violations and enforcement activities. Principal inspectors we
spoke with noted that the problems they typically found with air
ambulance operator certificates were generally tied to the
maintenance of proper paperwork and other record keeping
irregularities, and not to known industry safety issues such as
risk management and decision making. This may indicate that the
factors that frequently contribute to air ambulance accidents,
such as flying at night or in adverse weather, are not necessarily
addressed by typical FAA oversight activities, which focus on such
things as maintenance and training. Additionally, FAA was unable
to provide us with reliable data of FAA enforcement actions
related specifically to helicopter air ambulances because
enforcement data for operators do not distinguish the actions
taken against operators' air medical operations from operators'
other lines of business. For example, the core business of
Petroleum Helicopters International (PHI), one of the largest air
ambulance operators, consists of providing offshore helicopter
support to oil and gas companies operating in the Gulf of Mexico.
FAA enforcement data we reviewed for PHI do not specify which
enforcement actions were taken against the company's air medical
operations and its offshore operations. Moreover, FAA only
maintains data on enforcement actions taken against air ambulance
operators currently in operation. These data limitations constrain
FAA's ability to assess its air ambulance oversight activities and
are similar to the concerns we have previously reported about
FAA's inadequate evaluative processes with its inspections and
enforcement program.^30
Part 135 Regulations Do Not Address Specific Dangers Inherent in
Air Ambulance Transports
Many air ambulance flights are subject to different weather and
crew-rest requirements under federal aviation regulations,
depending on whether patients or passengers are on board. For
example, flights without patients or passengers, such as flights
en route to an accident scene or as part of training exercises,
are subject to minimum requirements outlined in Part 91
regulations. When patients are on board, Part 135 requirements are
applicable. Some operators we interviewed and visited reported
that it is their company policy to follow Part 135 requirements at
all times and believed that the more stringent requirements of
Part 135 regulations offer safer operating parameters.^31
Despite its more stringent requirements, Part 135 regulations
cover a broad range of operators and do not address the risks
inherent in the operational aspects of air ambulance
transports--adding to FAA's challenges in providing oversight of
the air ambulance industry. For example, Part 135 regulations do
not distinguish the operational control responsibilities of the
certificate holder from the base or hospital program, which may be
important in this industry because many air ambulance operations
are geographically dispersed or involve third parties, such as an
emergency medical system communications specialist or medical
director. In a recent review of Part 135 operators, FAA identified
a problem of questionable operational control being exercised by
certificate holders working under commercial arrangements with
aircraft owners or management companies. In December 2006, FAA
issued Notice 8000.347, which reiterates existing regulation about
the exercise of operational control. The notice outlines that
operational control requires Part 135 operators to "put procedures
in place to ensure that when safety conditions for a flight cannot
be met, the flight is canceled, delayed, rerouted, or diverted."
Because multiple people are involved in dispatching air ambulance
helicopters, operational control, as outlined within the current
Part 135 regulations, has been interpreted differently. According
to one FAA official, in some instances, tracking a flight or
"flight following"--one function of operational control--was being
performed by the hospital rather than the certificate holder
because the former entities were in two-way communication with the
helicopter. The official noted that this lack of formalized flight
following inhibits the efficacy of the certificate holder in
maintaining control of the aircraft and responsibility for the
flight at all times.
Part 135 regulations are also not tailored to the air ambulance
industry's scene response transports that often require flights to
remote sites. Remote-site flights may require crews to use new or
different flight routes that can be further complicated by
marginal weather or flying at night. Within Part 135 regulations,
instrument flight rules allow for the use of instruments in
guiding the aircraft in inclement weather. However, in order to
utilize instrument flight rules equipment, weather reporting must
be available for the destination location. According to Part 135
regulations, if such weather reporting is unavailable flights must
use visual flight rules (not instrument). According to some
operators, since many air ambulance flights are to remote landing
sites or to hospitals that do not have such weather reporting
available, air ambulances can be inhibited in their use of
instrument flight rules equipment under Part 135. ^32 Some
industry trade organizations consider flights that utilize
instruments to be much safer than the flights that rely solely on
visual cues.
FAA Efforts to Improve Safety Are Under Way, but Effects Are Not
Being Measured
While FAA has various efforts under way to address safety
oversight of the air ambulance industry, the agency currently is
not assessing the effects of these efforts. FAA's efforts have
taken three main forms. First, FAA has issued numerous items of
guidance for its inspectors and for air ambulance operators. The
guidance directed at air ambulance operators is not subject to
enforcement because it is not mandatory, and FAA has not
established a way to track the extent to which operators are
voluntarily implementing these practices. Second, FAA has
authorized additional inspectors to oversee large air ambulance
operators and taken other steps designed to improve the safety of
large operations. Third, FAA has increased collaboration with air
ambulance industry officials through sponsorship of and attendance
at meetings and conferences that address industry safety issues.
However, FAA has no way to measure the impacts of these safety
efforts because FAA does not collect basic data about industry
trends, such as flight hours, that are necessary to indicate if
accident rates are increasing or decreasing. Additionally, the
extent to which operators are following FAA voluntary guidance is
not currently tracked. Without an approach for evaluating the
effects of FAA efforts, it will be difficult to determine whether
the current approach and level of FAA safety oversight of the air
ambulance industry is appropriate.
FAA Guidance Focuses on Identified Safety Concerns
FAA has taken a number of steps to develop initiatives and
strategies to reduce the number of air ambulance accidents. In
August 2004, FAA established the FAA Emergency Medical Services
Task Force to review and guide government and industry efforts to
reduce air ambulance accidents. The FAA task force initiated a
collaborative relationship with air ambulance industry officials
that resulted in FAA developing and publishing numerous pieces of
aviation safety guidance, including FAA notices aimed at improving
the safety of air ambulances. Additionally, FAA has recently
authorized an increase in the size of the inspection teams
overseeing large air ambulance operators. Beyond the 2004 task
force, FAA has worked together with the industry in a number of
ways to help address the safety of air ambulances.
FAA has issued guidance for air ambulance inspectors and operators
that focus on a number of safety issues identified by the FAA task
force's review of air ambulance accidents (see table 3). FAA's
recently published guidance has been largely targeted at FAA
safety inspectors of air ambulance operators, but it also
recommends actions for operators to take to improve safety. All
published notices containing the guidance expire 1 year after
their effective date. Key areas of emphasis for inspectors to
relay to operators include improving decision-making skills, risk
management, and operational control.
^25Our analysis of NTSB data from 1998 through 2005 included 89 air
ambulance helicopter accidents and 1,129 non-air-ambulance helicopter
accidents.
^26FAA requires certificate holders to maintain a process for operational
control of their aircraft. FAA officials noted that operational control
should be (1) independent from the clinical or medical side of management
and operations, (2) dictated solely by criteria such as weather and
operational capability of crew and equipment, and (3) managed exclusively
by the certificate holder.
^27For more information, see Matthew J. Rigsby, FAA, U.S. Civil Helicopter
Emergency Medical Services Accident Data Analysis, the FAA Perspective
(September 2005).
^28GAO, Aviation Safety: FAA Management Practices for Technical Training
Mostly Effective; Further Actions Could Enhance Results, [30]GAO-05-728
(Washington, D.C.: Sept. 7, 2005).
^29FAA is shifting the oversight of commercial airlines (Part 121
carriers) to a new system--the Air Transportation Oversight System--and as
part of this realignment is restructuring the resources for geographic
oversight. This restructuring may affect the availability of geographic
resources for air ambulance oversight.
^30GAO, Aviation Safety: FAA's Safety Oversight System Is Effective but
Could Benefit from Better Evaluation of Its Programs' Performance,
[31]GAO-06-266T (Washington, D.C.: Nov. 17, 2005).
^31Our analysis of NTSB accident data (see app. II) showed that more
accidents occurred under Part 91 flight rules. However, because more
flights take place under Part 91 rules, it is difficult to tie the
accident record of Part 91 and Part 135 flights to safety.
^32FAA is considering a request from an air ambulance operator to perform
instrument flight rules departures and approach procedures at airports and
helipads that do not have an approved weather reporting source. If this
exemption to current Part 135 rules is approved by FAA, this operator
would be able to fly in accordance with instrument flight rules more often
and, according to the operator, thereby improve the safety of its Part 135
flights.
Table 3: Key FAA Published Efforts to Improve Air Ambulance Safety
Date Type of action Title Purpose
January 2005 Notice 8000.293 (on Helicopter Provides guidance for
Jan. 28, 2006, Emergency Medical FAA safety inspectors
became permanent Service Operations to help operators
through Safety review pilot and
Alert for Operators mechanic
06001) decision-making
skills, procedural
adherence, and crew
resource management
practices.
August 2005 Notice 8000.301 Operational Risk Provides guidance to
Assessment FAA inspectors to
Programs for promote improved risk
Helicopter assessment programs
Emergency Medical and risk management
Services tools and training to
all flight crews,
including medical
staff.
September Notice 8000.307 Special Emphasis Provides guidance to
2005 Inspection Program FAA safety inspectors
for Helicopter of air ambulance
Emergency Medical operators to place
Services emphasis on specific
areas, including
operational control
(policies, procedures,
training, etc), safety
culture development,
access to weather
information,
operators' knowledge
of geographic area,
etc.
September Advisory Circular Air Medical Provides guidance to
2005 00-64 Resource operators to establish
Management minimum training
guidelines for all air
medical team members.
January 2006 Flight Standards Helicopter Provides information
Handbook Bulletin Emergency Medical to inspectors about
for Air Services Loss of pilot training and
Transportation, Control and checking standards and
06-02 Controlled Flight requires a review of
into Terrain air ambulance operator
Accident Avoidance training programs.
Programs
January 2006 Flight Standards Helicopter Provides guidance to
Handbook Bulletin Emergency Medical principal operations
for Air Services; OpSpec inspectors about
Transportation, A021/A002 revisions to the
06-01 Revisions weather minimums for
air ambulance
operators.
March 2006 Notice 8000.318 Public Helicopter Provides guidance to
Emergency Medical inspectors to ensure
Services that public air
Operations ambulance operators
are aware of current
FAA policies and
standards for air
ambulance operations,
and to emphasize the
importance of public
aircraft operators'
compliance with these
operating rules.
August 2006 Aeronautical Helicopter Night Provides information
Information Manual Visual Flight Rule and guidance
Operations concerning night
celestial and man-made
lighting on seeing
conditions in night
visual flight rule
operations.
August 2006 Aeronautical Landing Zone Provides information
Information Manual Information and guidance on the
selection of ad-hoc
helicopter landing
sites by ground
responders and the use
of such sites by
helicopter operators.
November Notice 8000.333 [32]Helicopter Provides information
2006 Emergency Medical and guidance to
Services (HEMS) principal inspectors
use of the on the use of the
Aviation Digital ceiling and visibility
Data Service tool developed as a
(ADDS) result of the 2006
Experimental HEMS Weather Summit.
Tool
Source: FAA.
FAA notices require actions by FAA personnel but are nonmandatory to the
air ambulance operators and not subject to enforcement. For example, in
Notice 8000.301, which concerns risk assessment programs, principal
inspectors are to review the notice, provide a copy to their assigned
operators, and "strongly encourage" operators to implement a risk
assessment program. FAA inspectors told us that this published guidance is
difficult to enforce and agreed that although many of the air ambulance
operators are proactive in implementing FAA guidance, there is no way to
ensure that operators adopt the guidance. An official from Professional
Airways Systems Specialists, the union representing FAA inspectors, also
commented that principal inspectors have no way to compel operators to
adopt this guidance, because the enforcement tools they have (e.g.,
approving the operators' general operating manuals and levying sanctions
and fines) are rooted in established regulations, not in the "good ideas"
of the voluntary guidance. Additionally, FAA officials noted that in areas
where there has been some industry resistance, such as new equipment
recommendations, inspectors have little recourse. However, FAA officials
told us that rule making is a time-consuming process that can take years
to complete, hindering the agency's ability to quickly respond to emerging
issues. By issuing guidance rather than regulations, FAA has been able to
quickly respond to concerns about air ambulance safety. Officials added
that FAA has not ruled out future regulatory action.
Industry officials and air ambulance operators we interviewed were largely
supportive of FAA's efforts to provide additional guidance on air
ambulance safety and reported that most operators are implementing this
guidance. For example, CAMTS has adopted much of FAA's guidance within its
accreditation standards for operators and, in cases such as risk
assessment, has adopted more stringent standards than FAA encourages. Air
ambulance operators also reported that they were already operating at
higher standards than FAA recommends in guidance, such as weather minimums
and safety equipment. Many industry groups and operators do not believe
that additional regulations would be more effective than the published
guidance. For example, the Helicopter Association International, a
professional trade association for the civil helicopter industry, has
stated that adherence to current regulations is far more effective than
generating new regulations and has encouraged air ambulance operators to
adopt FAA guidance to the maximum extent possible to enhance safety.
Additional FAA Resources Allocated to Air Ambulance Oversight
FAA recently authorized the hiring of new inspectors to work on the
certificate management teams for large air ambulance operators. In 2005,
FAA sanctioned a group to review the resource needs for oversight of air
ambulance operators with 25 or more dedicated air ambulance helicopters.
Following this review, the task team made several recommendations to FAA
headquarters that included increasing the number of FAA inspectors
assigned to large air ambulance operators, dedicating these inspectors
solely to air ambulance operator certificates (i.e., no other inspection
responsibilities), and using the surveillance and evaluation program (SEP)
to identify risks and target surveillance activities.^33 As a result of
the task team recommendations, in June 2006, FAA accepted these
recommendations and authorized an increase in the number of staff assigned
to the inspection teams that oversee the seven large air ambulance
operators.^34 For four of the seven largest operators, the size of the
inspection teams will increase to eight inspectors to oversee the air
ambulance operator certificates.^35 Additionally, the principal inspectors
and newly hired inspectors for these operators will be dedicated to the
certificate. Prior to this effort, many of the principal inspectors for
large air ambulance operators were responsible for more than 20 different
certificates. Following this hiring, and implementation and use of SEP,
FAA will evaluate whether a further increase in inspection team sizes is
necessary. Hiring efforts by FAA to fill these inspector positions are
under way, and hiring is expected to be completed in fiscal year 2007.
FAA also initiated a series of efforts to improve the safety of one large
air ambulance operator in 2005, and officials reported that they hope some
of the changes and recommendations being adopted by this operator will be
implemented industrywide. FAA concluded that the recent increase in
accidents of this operator emphasized the need for a new approach to FAA's
involvement in the effort to enhance safety for air ambulance operators in
general. The team working with the operator has since recommended changes
to FAA to improve oversight, including increased and more focused
surveillance, relieving inspectors of other certificate duties, and adding
appropriately qualified inspectors. Additionally, the team has worked
closely with the operator to evaluate the company safety program,
encourage risk management, and to change some parameters for flights,
including weather minimums.
^33SEP is used by FAA in its oversight of commuter air carriers and is
considered to be a more effective and efficient surveillance program than
traditional, event-based surveillance. SEP emphasizes a system safety
approach of using risk analysis techniques and allows FAA inspectors to
prioritize workload based on areas of highest risk. For more information
on SEP, see GAO, Aviation Safety: System Safety Approach Needs Further
Integration into FAA's Oversight of Airlines, [33]GAO-05-726 (Washington,
D.C.: Sept. 28, 2005).
^34FAA district offices have initiated hiring efforts to staff to target
levels.
^35For the other large operators, inspection team sizes were increased
from three nondedicated inspectors to four dedicated inspectors.
FAA Has Increased Collaboration with the Industry
In addition to collaborating with the air ambulance industry on developing
FAA guidance, FAA officials have worked together with the industry in a
number of other ways, such as attending and participating in industry
meetings, conferences, and task teams. For example, in March 2006, FAA
hosted a Weather Summit to identify the air ambulance issues related to
weather products and services and determine how FAA can better meet
industry needs. Additionally, FAA officials participate in the AAMS Safety
Committee and have made presentations at recent industry conferences, such
as the Helicopter Safety Forum and the Air Medical Transport conference,
to keep the industry informed of FAA efforts related to air ambulance
oversight.
FAA officials also reported that they are working with the industry to
address recent NTSB safety concerns but have not issued any new
regulations for air ambulance operators as NTSB recommended. In its
January 2006 Special Investigation Report on air ambulance operations and
accidents, NTSB made four recommendations to FAA to improve air ambulance
safety (see table 4). With these recommendations NTSB encouraged FAA to
impose requirements for air ambulance operators because NTSB does not
anticipate that the recently published FAA guidance will be widely
implemented by operators due to its voluntary nature.^36
36According to NTSB, as of December 21, 2006, these recommendations are
still open.
Table 4: NTSB Recommendations and FAA Responses
NTSB recommendation to FAA FAA response
Require all air ambulance FAA is looking at options to address
operators to comply with Part concerns about the differences in the
135 operations specifications flight rules--specifically the weather
during the conduct of all minimums--through new weather reporting
flights with medical personnel requirements and the application of
on board. "eligible on demand" standards to air
ambulance helicopter operations.
Require all air ambulance FAA has implemented this recommendation
operators to develop and with the publication of Notice 8000.301.
implement flight risk
evaluation programs.
Require air ambulance FAA has a study under way to identify best
operators to use formalized industry practices in ground communication
dispatch and flight-following and dispatch to support effective FAA
procedures. requirements and policy.
Require air ambulance FAA has emphasized the strategic avoidance
operators to install terrain of controlled flight into terrain
awareness and warning systems accidents in Flight Standards Handbook
on their aircraft and to Bulletin for Air Transportation, 06-02. At
provide adequate training to FAA request, RTCA Inc., a private
ensure that flight crews are corporation, has formed a special
capable of using the systems. committee to develop the minimum
operational standards for helicopter
terrain awareness and warning systems,
which will be used by FAA in developing
future requirements.
Sources: NTSB and FAA.
Industry officials we spoke with generally agreed with the NTSB report
recommendations but did raise some concerns. Some industry officials were
concerned about the recommendation that air ambulances operate under Part
135 at all times, noting that this could inhibit transports in some areas
due to a lack of weather information. For example, in a response letter
addressed to NTSB, CAMTS stated that while the balance between lesser and
more stringent regulation has always been a concern, it is difficult to
operate under Part 135 regulations in rural areas due to airport and
landing restrictions. Additionally, many industry officials expressed
concerns about the costs related to implementing terrain awareness and
warning systems, and some stated that this technology may not be
appropriate for helicopters due to the low altitudes in which they
operate. For example, AAMS has stated that the NTSB has seriously
underestimated the costs involved in implementing terrain awareness and
warning systems and has pointed out that, on one aircraft, the cost of the
computer portion of this technology (which they say is the smallest part
of the implementation costs) can range from $14,000 to $30,000. AAMS
supports voluntary implementation of terrain awareness and warning systems
due to the high costs involved in implementing the systems and limited
proven benefits, especially in helicopter operations.
FAA Lacks an Approach for Evaluating the Effects of Its Efforts
While the efforts by FAA could have had an effect on safety, the extent of
any effect is unknown because FAA does not collect necessary data to
evaluate effectiveness. FAA efforts such as increasing its inspector
workforce allow FAA to conduct more inspections and potentially improve
oversight of air ambulance operators. However, whether this increased
attention results in a better safety record will be difficult to determine
without the data to conduct an analysis of the industry accident rate. FAA
does not currently collect basic data to measure changes in the air
ambulance industry, such as flight hours or number of trips flown. Without
data about the number of flights or flight hours, FAA and the air
ambulance industry are unable to identify whether the increased number of
accidents has resulted in an increased accident rate or whether it is a
reflection of the growing number of aircraft and programs. Data describing
the safety trends of the industry is essential to understanding the
effects of FAA efforts, especially as FAA continues to develop initiatives
and dedicate resources to improve air ambulance safety. NTSB has also
stated the need for valid activity data for Part 135 operators, not only
to compare accident rates, but also to establish baseline measures to be
used to identify and track accident trends and to assess the effectiveness
of safety improvement efforts.^37
Air ambulance flight hours and number of trips, while not currently
collected by FAA, appear readily available. According to current
regulations, Part 135 operators are not required to maintain flight-hour
activity data, but most FAA inspectors and air ambulance operators we
spoke with said that this information is available. Air ambulance
operators maintain records on the number of flights and flight hours for a
number of reasons, including to track the maintenance of the helicopter
equipment, to track the costs associated with flights (for billing
purposes), and to make business decisions such as where to place
additional aircraft or crew. Operators we spoke with did not express
concerns about reporting flight-hour or trip information to FAA. FAA
officials reported that principal inspectors can get this information from
operators, but regulatory changes would be necessary to require operators
to report it to FAA. To address the lack of national data, the industry
has an effort under way to create a database of air ambulance flight
operations information. This initiative is still in the preliminary
stages.
^37NTSB, Current Procedures for Collecting and Reporting U.S. General
Aviation Accident and Activity Data Safety Report (Washington, D.C., April
2005).
FAA also has no way to determine whether air ambulance operators are
implementing published guidance. Although FAA inspectors are required to
use FAA databases to record that guidance has been disseminated to air
ambulance operators, there is no mechanism to report whether operators
implemented the voluntary guidance. By issuing guidance for operators to
adopt, rather than making changes through regulations, FAA has expedited
the process of relaying safety information and encouraging safety
initiatives by operators. However, without a mechanism to record whether
operators are adopting this guidance, FAA is unable to link these efforts
to any specific results. For example, according to Notice 8000.293, FAA
inspectors were to encourage air ambulance operators to consider using
enhanced vision systems and terrain awareness and warning systems for
night operations. Without information about which operators adopted this
guidance, FAA will not be able to link this effort to safer flights or
fewer accidents and will thus be unable to determine whether voluntary
guidance is an effective means to direct air ambulance operator safety
efforts.
Conclusions
The number of air ambulance accidents, while decreasing somewhat over the
last 2 years, remains above historic levels. FAA and the industry have
implemented numerous efforts to improve the safety of air ambulances.
However, FAA lacks basic information on the industry and its safety
efforts, including the number of flights and flight hours, the number and
location of air ambulance aircraft, and the number of violations and
enforcement actions against air ambulance operations. This inhibits FAA's
ability to gain a complete understanding of the industry and whether its
efforts are sufficient. FAA needs data about the air ambulance fleet and
operations, as well as the ability to track and evaluate the
implementation of its voluntary guidance to operators. Without this
information, FAA cannot assess the safety of the industry. Further, this
lack of information makes it difficult to determine the extent to which
operators are making changes and the effect the efforts are having. Given
the differences between air ambulance operators and other Part 135
operators FAA oversees, as well as the challenges FAA faces in responding
to inherent safety concerns of the industry, a clear understanding of
trends and actions taken appears important in deciding if the current
regulatory approach is appropriate or if more fundamental changes, such as
revising FAA regulations or inspection processes, need to be considered.
Recommendations for Executive Action
To help FAA monitor industry growth trends, accident rates, and operator
implementation of FAA guidance, we recommend that the Secretary of
Transportation direct the Administrator of FAA to take the following two
actions:
o Identify the data necessary to better understand the air
ambulance industry and develop a systematic approach for gathering
and using this data. At a minimum, this data should include the
number of flights and flight hours, the number and locations of
air ambulance helicopters, and the number and types of FAA
violations and enforcement actions related to the air ambulance
fleet.
o Collect information on the implementation of voluntary FAA
guidance by air ambulance operators and evaluate the effectiveness
of that guidance.
Agency Comments and Our Evaluation
We provided a draft of this report to DOT for their review and
comment. On February 8, 2007, we met with DOT and FAA officials,
including the Deputy Director of FAA's Flight Standards Service,
to obtain their oral comments on the draft report. Overall, these
officials agreed with the report's findings and conclusions, and
agreed to consider the recommendations. FAA officials also
provided technical comments, which were incorporated in this
report, as appropriate. We also provided a draft of this report to
NTSB for their review and comment. On January 30, 2007, NTSB's
Audit Liaison provided technical comments, which were
incorporated, as appropriate, and confirmed that NTSB agreed with
the report's findings, conclusions, and recommendations via
e-mail. In addition, we provided a draft of this report to AAMS
since AAMS is a leading air ambulance industry representative.
AAMS provided written comments, which are reprinted in appendix
III. AAMS also provided technical comments, which were
incorporated, as appropriate.
As agreed with your office, unless you publicly announce the
contents of this report earlier, we plan no further distribution
until 14 days from the report date. At that time, we will send
copies to appropriate congressional committees, the Secretary of
Transportation, and the Chairman of the National Transportation
Safety Board. We will also make copies available to others on
request. In addition, the report is available at no charge on the
GAO Web site at http://www.gao.gov .
If you have any questions about this report, please contact me at
(202) 512-2834 or [email protected] . Contact points for our
Offices of Congressional Relations and Public Affairs may be found
on the last page of this report. GAO staff who made major
contributions to this report are listed in appendix IV.
Sincerely yours,
Gerald L. Dillingham, Ph.D.
Director, Physical Infrastructure
Issues
Appendix I: Scope and Methodology
To identify and describe the recent trends in the air ambulance
industry, we reviewed literature and analyzed data on industry
composition, size, and accidents. The literature we reviewed
included government, industry, and academic studies, reports, and
other documents regarding the evolution of the industry in terms
of composition, size, accidents, and safety initiatives. The
Federal Aviation Administration (FAA) data included estimates of
flight hours and aircraft based on its General Aviation and Air
Taxi Activity and Avionics survey for 1999 to 2004, data on
numbers of inspectors and operators (as of 2005), and numbers and
types of violations and enforcement actions from various FAA
databases for 1998 to 2005. The Association of Air Medical
Services data, from the Atlas and Database of Air Medical
Services, included numbers of bases and dedicated aircraft for
2003 to 2005. To examine the relationship between changes in
Medicare reimbursement rules and industry trends, we analyzed data
on Medicare reimbursed air ambulance trips from 1998 to 2005, as
well as trips by type of air ambulance provider for 2001 and 2004;
these data were obtained from the Medicare claims database. Based
on reviews of data documentation, interviews with relevant
officials, and tests for reasonableness, we determined that the
data we used were sufficiently reliable for the purposes of our
study. We also interviewed officials from the National
Transportation Safety Board (NTSB), academic experts, and industry
and trade group representatives about trends in the nature and
scope of the industry and overall safety concerns. Table 5 lists
the industry and trade organizations we contacted.
Table 5: Industry and Trade Organizations Interviewed
Source: GAO.
To assess challenges to FAA oversight, we reviewed federal laws,
regulations, and guidance on air ambulance safety to better
understand the nature and extent of FAA's oversight role. Further,
we interviewed FAA Flight Standards officials in headquarters,
inspectors, and certificate management teams for air ambulance
operators, as well as industry officials and other experts, about
air ambulance safety and challenges to FAA oversight.
To help identify the key safety risks, we obtained and analyzed
data from NTSB's Aviation Accident Database on accidents that
occurred from January 1, 1998, to December 31, 2005. Our analysis
of the NTSB data formed the basis of the descriptive and
comparative information on air ambulance accidents shown
throughout this report. According to NTSB, an aviation accident is
"an occurrence associated with the operation of an aircraft which
takes place between the time any person boards the aircraft with
the intention of flight and all such persons have disembarked, and
in which any person suffers death or serious injury, or in which
the aircraft receives substantial damage." Accidents were included
in our analysis as a helicopter air ambulance accident if the
database showed (1) the accident involved a helicopter being
operated by an air medical transport company and (2) the accident
occurred during flight under either Part 91 or Part 135
regulations. For this period, we identified a total of 89
helicopter air ambulance accidents that occurred under Part 91 or
Part 135 flight rules and analyzed data about these accidents to
determine key contributing causes and factors.^1 All accidents
involving public operators were excluded from our analysis. We
also conducted analyses comparing these 89 air ambulance accidents
with other helicopter accidents during the same time period.
To assess the reliability of the NTSB data, we (1) performed
electronic testing for accuracy, completeness, and consistency;
(2) reviewed internal NTSB documents about its collection, entry,
and maintenance; and (3) interviewed officials in NTSB's Office of
Aviation Safety and Office of Research and Engineering who were
knowledgeable about the content and limitations of these data. We
determined that these data were sufficiently reliable for the
nationwide descriptive and comparative analyses used in this
report. We documented the procedures that we used in our analyses
and submitted them to officials in NTSB's Office of Research and
Engineering for their review and concurrence.
To learn more about air ambulance safety risks and concerns, we
conducted a total of five site visits of air ambulance providers
in Arizona, California, Maryland, Texas, and Washington. We chose
these states based on the presence of a large air ambulance
market,^2 state accreditation requirements, or an operating public
provider. To have access to a greater number of providers
representing a variety of business models, operational
characteristics, and accident histories, we narrowed our possible
site visit locations to large air ambulance markets. To examine
the relevance and describe the extent of state accreditation
requirements, we included states with and without these
requirements. Lastly, to learn about the policies and practices
public providers may be engaged in that impact safety, we chose
states that had a public operator.
We selected the providers based on a number of operational
characteristics to include a variety of business models
(hospital-based and stand-alone programs, and public and private
programs) and certificate holder arrangements (operating
certificate held by program or vendor). During these site visits,
we interviewed company officials, including pilots, and obtained
documentation of some programs' flight safety protocols. Table 6
provides a description of each state we visited.
Organizations
Air Medical Physicians Association
Air Medical Safety Advisory Council
Air, Surface, and Transport Nurses Association
Association of Air Medical Services
Commission on Accreditation of Medical Transport Systems
Helicopter Association International
International Association of Flight Paramedics
National Association of Air Communications Specialists
National Association of State Emergency Medical Services Officials
National Emergency Medical Services Pilots Association
Professional Airways Systems Specialists
R. Dixon Speas Associates
^1There is no clear consensus about what constitutes an air ambulance
accident; thus, other studies may present different accident totals
covering the same time period.
^2Large air ambulance markets were determined by state using the total
number of bases and aircrafts as identified in the Atlas and Database of
Air Medical Services. After states had been identified as having the
greatest number of bases and aircrafts, metropolitan regions were chosen
on the basis of having the greatest number of operators present in the
area.
Table 6: Description of States Selected for Site Visits
Description of air ambulance
State market Description of programs visited
Arizona Providers: 10 o Native Air, a subsidiary of
Omniflight Helicopters, is a
Helicopters: 50 community-based operator, and
its fleet is composed of 15
Accidents, 1998 to 2005: 8 helicopters located at 12
bases in Arizona and Montana.
State requirements: The state
requires licensing for all
air ambulance providers
through the Arizona
Department of Health
Services. Inspection and
registration for all air
ambulance units operating in
Arizona is required on a
yearly basis. If a provider
is accredited by the
Commission on Accreditation
of Medical Transport Systems
(CAMTS), the state
requirement for a licensure
inspection is waived.
California Providers: 28 o The FlightCare Program at
Enloe Medical Center is a
Helicopters: 72 nonprofit hospital-based
program. The program's fleet
Accidents, 1998 to 2005: 7 consists of one helicopter
based at the Enloe Hospital
State requirements: The state helipad.
of California has delegated o REACH is an independent
authority to local for-profit air ambulance
governments for emergency provider. The company has
medical services (EMS). seven helicopters and nine
County governments are bases in California and
responsible for coordinating Oregon.
emergency medical services, o CALSTAR is a nonprofit
including the coordination community-based program. The
and monitoring of air company's fleet consists of 11
ambulance services. helicopters and seven bases in
California.
o The California Highway
Patrol operates as an air
rescue provider. The
California Highway Patrol
maintains a fleet of 14
helicopters, 11 of which are
partially used for medical
emergency transport and air
rescue. These helicopters are
based at nine locations
throughout the state.
Maryland Providers: 3 o The Maryland State Police
Aviation Command is a public
Helicopters: 18 provider and has a fleet of 12
helicopters based in eight
Accidents, 1998 to 2005: 1 locations across the state.
State requirements: Maryland
requires private providers of
air ambulance services
operating in the state to be
licensed by the state and
CAMTS accredited.
Texas Providers: 23 o Teddy Bear Transport of Cook
Children's Medical Center is a
Helicopters: 61 hospital-based program that
conducts hospital-to-hospital
Accidents, 1998 to 2005: 13 transports for pediatric
patients. The program
State requirements: The state contracts with a vendor for
requires air ambulances and its aviation services and
providers to be licensed by operates one helicopter.
the Texas Department of State o PHI Air Medical is an
Health Services. The independent program conducting
licensure process requires a mix of scene response and
providers to submit a copy of hospital-to-hospital
their current FAA operational transports. PHI's programs in
certification that includes Texas include 12 helicopters
designation for air ambulance stationed at 12 bases. In
operations. total, the company has 224 air
ambulance helicopters
stationed at 49 bases in 14
states.
Washington Providers: 2 o Airlift Northwest is a
nonprofit community-based
Helicopters: 10 program. The program contracts
out its aviation services. Its
Accidents, 1998 to 2005: 3 fleet consists of six
helicopters stationed at four
State requirements: The state bases in Washington.
requires providers and air
ambulances to be licensed
through the Washington
Department of Health.
Providers must be accredited
by CAMTS. Air ambulance
licensure applicants must
affirm in the application
that their service meets all
FAA regulations, and they
must also provide a copy of
their current FAA certificate
and operational
specifications.
Source: GAO.
To supplement information gathered through interviews and visits with
local program officials, we also conducted semistructured interviews with
management officials from five of the largest air ambulance operators to
discuss air ambulance safety and trends. We also met with local geographic
and assigned principal FAA inspectors to learn more about their roles and
responsibilities in the oversight of the programs we visited.
To describe the FAA efforts in addressing safety oversight challenges, we
identified and reviewed regulatory and voluntary guidance implemented by
FAA to address safety in the air ambulance industry. We reviewed advisory
circulars, notices, and other guidance issued by FAA since 2004. We also
obtained and reviewed documentation of FAA's heightened oversight of one
air ambulance operator and other documents regarding staffing levels for
the certificate management teams of large air ambulance operators.
Appendix II: NTSB Air Ambulance Accident Data
According to NTSB, from January 1998 through 2005, 89 air ambulance
accidents took place, resulting in 75 fatalities, 31 serious injuries, and
27 minor injuries. An additional 133 people involved in these accidents
suffered no injuries. Of the 89 accidents, 64 took place during Part 91
flight and the remaining 25 took place during Part 135 flight. Forty-seven
of the accidents took place during the night and the remaining 42 took
place during the day. Table 7 provides information collected from NTSB on
each of these accidents.
Table 7: NTSB Air Ambulance Accident Information, 1998 through 2005
Number of
When fatalities,
Flight accident injuries, or
Year regulation occurred uninjured State Accident details
1998 135 Night 4 fatalities UT An air ambulance helicopter
transporting an injured
skier to a hospital was
destroyed when it collided
with mountainous terrain
after flying into known
adverse weather.
1998 91 Day 3 injuries AR An air ambulance helicopter
en route to pick up a
patient from a hospital was
substantially damaged during
a hard landing following a
loss of engine power.
1998 91 Night 3 fatalities TX An air ambulance helicopter
en route to an accident
scene collided with terrain
and trees after encountering
poor visibility conditions.
1998 91 Night 3 uninjured CA An air ambulance helicopter
was destroyed when it rolled
over while attempting to
land at a makeshift landing
zone near an accident site.
1998 91 Night 3 fatalities IA Due to faulty components, an
air ambulance helicopter
experienced an in-flight
breakup during descent and
was destroyed.
1998 135 Night 4 uninjured ID An air ambulance helicopter
taking off from an off-site
landing zone sustained
substantial damage when it
collided with wires.
1999 91 Night 3 injuries OH An air ambulance helicopter
en route to pick up a
patient from a hospital was
destroyed when it impacted a
house after the pilot
inadvertently entered snowy
conditions.
1999 135 Day 5 uninjured TX An air ambulance helicopter
transporting a patient to a
hospital from an accident
scene was substantially
damaged when it impacted
power lines during takeoff.
1999 91 Night 3 fatalities NV An air ambulance helicopter
returning to base after
transporting a patient to a
hospital was destroyed after
encountering deteriorating
weather conditions and
colliding with terrain.
1999 91 Day 3 uninjured FL An air ambulance helicopter
en route to pick up a
patient collided with a
building while hovering in
preparation for takeoff.
1999 91 Day 1 uninjured MO An air ambulance helicopter
impacted terrain (during
takeoff from a helipad
located on top of a
hospital) because an
auxiliary power line was
still attached to the
helicopter.
1999 91 Night 3 injuries FL An air ambulance helicopter
crashed when approaching an
off-site landing zone to
pick up a patient.
1999 135 Day 4 uninjured MT An air ambulance helicopter
collided with a tower during
takeoff from a remote site.
2000 91 Night 3 uninjured TN An air ambulance helicopter
was substantially damaged
when it collided with a tree
while attempting to land at
a roadside landing zone.
2000 135 Night 4 fatalities TX An air ambulance helicopter
transporting a patient to a
hospital was destroyed when
it impacted terrain after
flying into known adverse
weather conditions.
2000 91 Day 2 uninjured MN An air ambulance helicopter
returning from dropping off
a patient was substantially
damaged from an in-flight
collision with a warehouse.
2000 91 Day 3 fatalities FL An air ambulance helicopter
traveling back to base after
completing an interfacility
transport collided with a
radio transmission tower and
was destroyed.
2000 91 Night 3 uninjured TX An air ambulance helicopter
was substantially damaged
when the tail rotor
contacted trees while
attempting to land at an
accident site.
2000 91 Night 3 fatalities GA An air ambulance helicopter
returning to base was
destroyed when it collided
with trees and the ground
during flight.
2000 91 Day 1 uninjured MN An air ambulance helicopter
departing for refueling was
substantially damaged during
takeoff from a hospital
helipad during windy
conditions.
2000 135 Day 4 injuries AZ An air ambulance helicopter
attempting to airlift a
seriously injured patient
impacted trees and terrain
and was substantially
damaged.
2000 91 Night 1 fatality NC An air ambulance helicopter
experiencing mechanical
difficulties collided with
terrain and was destroyed.
The accident occurred after
a mechanic had taken
insufficient action to fix
the problem.
2000 91 Night 3 uninjured NV An air ambulance helicopter
attempting to pick up a
patient at a remote site
collided with the ground
during an aborted landing
and sustained substantial
damage.
2000 91 Night 3 injuries AZ An air ambulance helicopter
on a positioning flight
sustained substantial damage
when the pilot became ill
and lost control just before
landing.
2001 91 Night 1 injury, IL An air ambulance helicopter
readying for takeoff
2 uninjured received minor damage when a
hospital security guard
walked into the tail rotor.
2001 91 Day 1 fatality CO An air ambulance helicopter
conducting a postmaintenance
flight check was destroyed
when it impacted the ground
after losing rotor speed.
2001 91 Day 2 injuries NY An air ambulance helicopter
on a positioning flight was
substantially damaged during
a precautionary landing
following a mechanical
malfunction.
2001 91 Day 3 uninjured WY An air ambulance helicopter
conducting an off-site
landing was substantially
damaged when its tail rotor
impacted a barrel.
2001 91 Day 3 uninjured AZ An air ambulance helicopter
on a positioning flight was
substantially damaged during
a forced landing following a
reported loss of engine
power.
2001 135 Day 4 uninjured OR An air ambulance helicopter
departing an off-site
landing zone had to conduct
an emergency landing because
of a fire in the aircraft.
2001 91 Day 3 injuries TX An air ambulance helicopter
en route to pick up a
patient was substantially
damaged when it impacted
trees and terrain following
a loss of engine power.
2001 135 Day 4 uninjured CA An air ambulance helicopter
encountering low visibility
conditions rolled onto its
side during takeoff from a
remote location.
2001 91 Night 1 fatality, CA An air ambulance helicopter
attempting to land at an
1 injury, off-site landing zone was
destroyed when it
1 uninjured encountered brownout
conditions and collided with
trees.
2001 91 Night 2 injuries, TX An air ambulance helicopter
on a nighttime positioning
1 uninjured flight was substantially
damaged during a hard
landing following a total
loss of engine power.
2001 91 Night 1 injury ID An air ambulance helicopter
on a nighttime repositioning
flight was destroyed when it
collided with terrain after
the pilot became spatially
disoriented.
2002 91 Night 2 fatalities, OH An air ambulance helicopter
was destroyed when it
1 injury collided with a brick
fac,ade during a takeoff
from a rooftop helipad in
windy conditions.
2002 91 Day 1 fatality, CA An air ambulance helicopter
en route to pick up a
2 injuries patient was substantially
damaged when the pilot
became visually disoriented
and collided with the
surface of a lake.
2002 91 Night 3 uninjured AR An air ambulance helicopter
was substantially damaged
when its tail rotor struck
trees during an approach to
a landing zone.
2002 91 Day 3 uninjured FL An air ambulance helicopter
experiencing mechanical
trouble was substantially
damaged when it performed a
forced landing.
2002 91 Day 3 fatalities NE An air ambulance helicopter
en route to pick up a
patient was destroyed when
it experienced a loss of
control and a corresponding
collision with terrain.
2002 135 Night 5 uninjured FL An air ambulance helicopter
transporting a patient had
an engine fire and was
forced to conduct an
emergency landing.
2002 91 Day 4 injuries FL An air ambulance helicopter
en route to pick up a
patient collided with a
corner of a multistory
parking garage during
takeoff from a hospital
helipad.
2002 91 Night 3 fatalities CA An air ambulance helicopter
en route to an accident
scene was destroyed after
impacting terrain while
maneuvering.
2002 135 Night 4 fatalities SD An air ambulance helicopter
completing a nighttime
interfacility transport
crashed into terrain and was
destroyed after the pilot
lost control.
2002 91 Day 3 uninjured TX An air ambulance helicopter
sustained substantial damage
following a loss of control
while attempting to take off
from a hospital helipad.
2002 91 Day 1 uninjured KY An air ambulance helicopter
experiencing a loss of
control was substantially
damaged during an emergency
landing at an off-site
landing zone.
2002 135 Day 4 uninjured WA An air ambulance helicopter,
while conducting an
interfacility transport,
sustained substantial damage
when it encountered whiteout
snow conditions and
completed a hard emergency
landing.
2002 91 Night 3 uninjured NY An air ambulance helicopter
was substantially damaged
after encountering a gust of
wind during an engine
startup on a rooftop
helipad.
2003 91 Night 2 fatalities, UT An air ambulance helicopter
crashed into terrain after
1 injury encountering dense fog while
on an aborted mission to
pick up a patient.
2003 91 Night 1 fatality IL An air ambulance helicopter
operating in reduced
visibility conditions was
destroyed as a result of a
collision with terrain.
2003 91 Day 1 injury, TX An air ambulance helicopter
en route to pick up a
2 uninjured patient for interfacility
transport sustained
substantial damage when it
impacted terrain during a
hard landing.
2003 91 Day 3 uninjured TX An air ambulance helicopter
was substantially damaged
after a tail rotor drive
failed during flight as a
result of a blanket coming
into contact with the tail
rotor blades due to an
unsecured cargo door.
2003 135 Night 1 uninjured MI An air ambulance helicopter
at an off-site landing zone
was substantially damaged
when the tail rotor impacted
a roadway sign during an
aerial taxi.
2003 91 Day 3 uninjured PA An air ambulance helicopter
conducted an emergency
landing because a flashlight
left on the tail boom came
into contact with the tail
rotor blades.
2003 91 Day 1 fatality, UT An air ambulance helicopter
en route to its home base
1 injury, after completing a patient
transport was destroyed when
1 uninjured it impacted a hillside.
2003 135 Day 3 injuries, FL An air ambulance helicopter
crashed while attempting to
1 uninjured take off from an off-site
landing zone.
2003 91 Day 3 injuries NY An air ambulance helicopter
was substantially damaged
during a forced landing when
the pilot misinterpreted
power loss.
2003 135 Day 4 uninjured CA An air ambulance helicopter
in the process of
transporting a patient made
an emergency off-airport
landing after experiencing
severe in-flight vibrations.
2003 91 Night 3 uninjured IL An air ambulance helicopter
executed a precautionary
landing to a vacant parking
lot after the helicopter
encountered an in-flight
vibration.
2003 91 Night 1 injury, TX An air ambulance helicopter
sustained substantial damage
2 uninjured when it impacted a safety
fence and rolled over during
an aborted takeoff following
a partial loss of engine
power.
2003 135 Night 3 uninjured IN An air ambulance helicopter
sustained substantial damage
during a hard landing in a
gravel lot after losing
visibility due to dust.
2003 135 Day 4 uninjured AZ An air ambulance helicopter
transporting a patient
experienced a loss of
control due to mechanical
failure and crashed on a
taxiway during an emergency
landing.
2003 91 Day 1 injury AR An air ambulance helicopter
was substantially damaged
following a loss of control
during engine start because
the main rotor was still
tied down.
2003 91 Night 3 uninjured TX An air ambulance helicopter
readying for an off-site
landing sustained
substantial damage when the
tail rotor blades impacted
trees while maneuvering.
2003 91 Night 3 uninjured KY An air ambulance helicopter
landing at an off-site
landing zone was
substantially damaged when
its tail rotor struck a
hydrant that had not been
identified by ground
personnel.
2003 91 Night 3 fatalities CA An air ambulance helicopter
on the way to pick up a
patient crashed into
mountainous terrain during
high winds and heavy rain.
2004 135 Night 4 fatalities, TX An air ambulance helicopter
transporting a patient
1 injury crashed into terrain while
maneuvering in reduced
visibility.
2004 135 Night 1 fatality, IN An air ambulance helicopter
transporting a patient was
3 injuries substantially damaged when
it collided with terrain.
2004 91 Day 3 uninjured TX An air ambulance helicopter
sustained substantial damage
when its tail rotor struck a
parked helicopter while
hovering prior to takeoff
from a helipad.
2004 91 Day 3 uninjured AZ An air ambulance helicopter
landing at an off-site
landing zone was
substantially damaged after
a hard landing in low
visibility conditions.
2004 135 Night 4 fatalities SC An air ambulance helicopter
flying in mist and light fog
collided with trees shortly
after picking up a patient
at an Interstate accident
site.
2004 135 Day 4 uninjured ID An air ambulance helicopter
was substantially damaged
while maneuvering at an
accident site during windy
conditions.
2004 135 Night 5 fatalities NV An air ambulance helicopter
crashed into mountainous
terrain at night and in
deteriorating weather
conditions.
2004 91 Night 1 injury NM An air ambulance helicopter
on a positioning flight was
substantially damaged after
liftoff when the
helicopter's skid struck the
helipad and caused the
helicopter to roll over.
2004 91 Night 3 fatalities FL An air ambulance helicopter
attempting to return to base
after abandoning a mission
due to bad weather was
destroyed when it crashed
into water.
2004 91 Day 3 uninjured AZ An air ambulance helicopter
flying to pick up a patient
experienced a partial power
loss, followed by a hard
landing in a parking lot.
2004 135 Night 2 injuries, OK An air ambulance helicopter
was substantially damaged
1 uninjured when it impacted terrain
following a loss of control
due to a blanket coming in
contact with the tail rotor
blades during flight.
2004 91 Night 1 fatality, AZ An air ambulance helicopter
was destroyed when it
2 injuries collided with terrain while
attempting to land at an
off-site landing zone.
2005 91 Day 1 injury, AZ An air ambulance helicopter
readying to land at an
1 uninjured airport experienced loss of
control and collided with
terrain.
2005 91 Night 1 fatality MS An air ambulance helicopter
was destroyed after
colliding with trees and the
ground in adverse weather
conditions.
2005 91 Night 2 fatalities, MD An air ambulance helicopter
returning to base was
1 injury destroyed after impacting
water.
2005 135 Day 1 fatality, AR An air ambulance helicopter
transporting a patient lost
3 injuries control and was
substantially damaged during
a hard landing.
2005 91 Day 3 fatalities CO An air ambulance helicopter
was substantially damaged
when it impacted terrain
while approaching an
off-site landing zone.
2005 135 Day 4 uninjured IN An air ambulance helicopter
was substantially damaged
following an in-flight loss
of control after it impacted
the helipad after takeoff.
2005 91 Day 3 uninjured FL An air ambulance helicopter
sustained substantial damage
when it rolled over while
conducting an emergency
landing after takeoff.
2005 91 Night 3 fatalities WA An air ambulance helicopter
was destroyed when it
impacted ocean waters while
returning to base.
2005 91 Night 1 fatality PA An air ambulance helicopter
on a refueling flight was
destroyed when it impacted
trees and terrain while
performing an instrument
approach to the airport.
2005 135 Night 1 injury, WA An air ambulance helicopter
during takeoff sustained
3 uninjured substantial damage after
impacting an object and
subsequently impacting
terrain.
2005 91 Day 3 uninjured MN An air ambulance helicopter
sustained substantial damage
during an aborted takeoff
after a loss of power.
Source: GAO analysis of NTSB data.
Appendix III: Comments from the Association of Air Medical Services
Appendix IV: GAO Contact and Staff Acknowledgments
GAO Contact
Gerald L. Dillingham, Ph.D., (202) 512-2834 or [email protected]
Staff Acknowledgments
In addition to the contact named above, Nikki Clowers, Assistant Director;
Ashley Alley; David Hooper; Brooke Leary; Heather MacLeod; Mitchell
Karpman; Sara Ann Moessbauer; Stan Stenersen; Friendly Vang-Johnson; and
Pamela Vines made key contributions to this report.
(540123)
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Highlights of [43]GAO-07-353 , a report to the Chairman, Subcommittee on
Aviation, Committee on Transportation and Infrastructure, House of
Representatives
February 2007
AVIATION SAFETY
Improved Data Collection Needed for Effective Oversight of Air Ambulance
Industry
Air ambulance transport is widely regarded as improving the chances of
survival for trauma victims and other critical patients. However, in
recent years, the number of air ambulance accidents has led to increased
industry scrutiny by government agencies, the public, the media, and the
industry itself. The Federal Aviation Administration (FAA), which provides
safety oversight, has been called upon by the National Transportation
Safety Board (NTSB) and others to issue more stringent safety requirements
for the industry.
GAO's study addressed (1) recent trends in the air ambulance industry, (2)
FAA's challenges in providing safety oversight, and (3) FAA's efforts to
address the challenges and what is known about the effects of these
efforts. To address these issues, we analyzed FAA, NTSB, and industry
data, interviewed federal and industry officials, and conducted five site
visits, among other things.
[44]What GAO Recommends
GAO recommends that FAA (1) identify the data necessary to better
understand the air ambulance industry and develop a systematic approach
for gathering and using this data and (2) collect information to evaluate
the effectiveness of voluntary FAA guidance. DOT agreed with our findings
and conclusions, and agreed to consider our recommendations.
From 1998 to 2005, the air ambulance industry grew, largely in stand-alone
(independent) operations, and experienced an increased number of
accidents, resulting in added industry efforts to improve safety. Although
there are few data on the industry's basic aspects, available data show
increased numbers of helicopters and base stations between 2003 and 2005.
Most of the base-station growth has been at airports and stand-alone
helipads rather than hospital-based locations, a strong indication of the
shift to stand-alone operations. The annual number of accidents increased
from 1998 to 2003 but declined in 2004 and 2005. The decline may reflect
added industry safety efforts, such as the creation of a study group that
recommends best practices. However, the lack of actual flight-hour data
prevents calculation of the industry's accident rate, making it difficult
to determine whether the industry has become more or less safe.
FAA's main challenge in providing safety oversight for air ambulances is
that its oversight approach is not geared toward air ambulance operations.
For example, FAA uses the same set of regulations to oversee air ambulance
operations as it uses to oversee other air taxi services. Air ambulance
flights are subject to greater risks than other helicopter operations
because they often fly at night, in a variety of weather conditions, and
to remote sights to provide medical attention. These transports also can
involve multiple medical and aviation officials, increasing the potential
for human error. The broad nature of the applicable regulations further
inhibits FAA oversight because they may not fully address the potential
risks air ambulance operations face.
FAA has initiated many efforts to strengthen its oversight of air
ambulances but does not evaluate the effectiveness of its efforts. FAA's
efforts include establishing a task force to review air ambulance
accidents, plans for hiring additional staff to oversee large operators,
and issuing guidance to inspectors and operators promoting various safety
practices. However, FAA does not track implementation of its voluntary
guidance. Also, FAA cannot measure basic industry trends, such as accident
rate changes. Measuring these trends requires actual flight-hour data,
which FAA does not currently collect. Without this data, FAA cannot know
if its efforts are achieving their intended results.
Air Ambulance Helicopter
References
Visible links
30. http://www.gao.gov/cgi-bin/getrpt?GAO-05-728
31. http://www.gao.gov/cgi-bin/getrpt?GAO-06-266T
32. http://www.faa.gov/library/manuals/examiners_inspectors/8000/media/N8000-333.pdf
33. http://www.gao.gov/cgi-bin/getrpt?GAO-05-726
43. http://www.gao.gov/cgi-bin/getrpt?GAO-07-353
*** End of document. ***