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Effective Oversight of Air Ambulance Industry' which was released on 
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Report to the Chairman, Subcommittee on Aviation, Committee on 
Transportation and Infrastructure, House of Representatives: 

United States Government Accountability Office: 

GAO: 

February 2007: 

Aviation Safety: 

Improved Data Collection Needed for Effective Oversight of Air 
Ambulance Industry: 

GAO-07-353: 

GAO Highlights: 

Highlights of GAO-07-353, a report to the Chairman, Subcommittee on 
Aviation, Committee on Transportation and Infrastructure, House of 
Representatives 

Why GAO Did This Study: 

Air ambulance transport is widely regarded as improving the chances of 
survival for trauma victims and other critical patients. However, in 
recent years, the number of air ambulance accidents has led to 
increased industry scrutiny by government agencies, the public, the 
media, and the industry itself. The Federal Aviation Administration 
(FAA), which provides safety oversight, has been called upon by the 
National Transportation Safety Board (NTSB) and others to issue more 
stringent safety requirements for the industry. 

GAO’s study addressed (1) recent trends in the air ambulance industry, 
(2) FAA’s challenges in providing safety oversight, and (3) FAA’s 
efforts to address the challenges and what is known about the effects 
of these efforts. To address these issues, we analyzed FAA, NTSB, and 
industry data, interviewed federal and industry officials, and 
conducted five site visits, among other things. 

What GAO Found: 

From 1998 to 2005, the air ambulance industry grew, largely in stand-
alone (independent) operations, and experienced an increased number of 
accidents, resulting in added industry efforts to improve safety. 
Although there are few data on the industry’s basic aspects, available 
data show increased numbers of helicopters and base stations between 
2003 and 2005. Most of the base-station growth has been at airports and 
stand-alone helipads rather than hospital-based locations, a strong 
indication of the shift to stand-alone operations. The annual number of 
accidents increased from 1998 to 2003 but declined in 2004 and 2005. 
The decline may reflect added industry safety efforts, such as the 
creation of a study group that recommends best practices. However, the 
lack of actual flight-hour data prevents calculation of the industry’s 
accident rate, making it difficult to determine whether the industry 
has become more or less safe. 

FAA’s main challenge in providing safety oversight for air ambulances 
is that its oversight approach is not geared toward air ambulance 
operations. For example, FAA uses the same set of regulations to 
oversee air ambulance operations as it uses to oversee other air taxi 
services. Air ambulance flights are subject to greater risks than other 
helicopter operations because they often fly at night, in a variety of 
weather conditions, and to remote sights to provide medical attention. 
These transports also can involve multiple medical and aviation 
officials, increasing the potential for human error. The broad nature 
of the applicable regulations further inhibits FAA oversight because 
they may not fully address the potential risks air ambulance operations 
face. 

FAA has initiated many efforts to strengthen its oversight of air 
ambulances but does not evaluate the effectiveness of its efforts. 
FAA’s efforts include establishing a task force to review air ambulance 
accidents, plans for hiring additional staff to oversee large 
operators, and issuing guidance to inspectors and operators promoting 
various safety practices. However, FAA does not track implementation of 
its voluntary guidance. Also, FAA cannot measure basic industry trends, 
such as accident rate changes. Measuring these trends requires actual 
flight-hour data, which FAA does not currently collect. Without this 
data, FAA cannot know if its efforts are achieving their intended 
results. 

Figure: Air Ambulance Helicopter: 

[See PDF for Image] 

Source: Clare McLean 2006. 

[End of figure] 

What GAO Recommends: 

GAO recommends that FAA (1) identify the data necessary to better 
understand the air ambulance industry and develop a systematic approach 
for gathering and using this data and (2) collect information to 
evaluate the effectiveness of voluntary FAA guidance. DOT agreed with 
our findings and conclusions, and agreed to consider our 
recommendations. 

[Hyperlink, http://www.gao.gov/cgi-bin/getrpt?GAO-07-353]. 

To view the full product, including the scope and methodology, click on 
the link above. For more information, contact Gerald L. Dillingham, 
Ph.D., at (202) 512-2834 or dillinghamg@gao.gov. 

[End of figure] 

Contents: 

Letter: 

Results in Brief: 

Background: 

Increase in Size and Safety-Related Concerns Mark Industry's Recent 
Years: 

FAA Safety Oversight Does Not Fully Address Industry's Operational 
Risks: 

FAA Efforts to Improve Safety Are Under Way, but Effects Are Not Being 
Measured: 

Conclusions: 

Recommendations for Executive Action: 

Agency Comments and Our Evaluation: 

Appendix I: Scope and Methodology: 

Appendix II: NTSB Air Ambulance Accident Data: 

Appendix III: Comments from the Association of Air Medical Services: 

Appendix IV: GAO Contact and Staff Acknowledgments: 

Tables: 

Table 1: Examples of Independent and Hospital-Based Operators: 

Table 2: Examples of Air Ambulance Industry Initiatives to Address 
Safety Concerns: 

Table 3: Key FAA Published Efforts to Improve Air Ambulance Safety: 

Table 4: NTSB Recommendations and FAA Responses: 

Table 5: Industry and Trade Organizations Interviewed: 

Table 6: Description of States Selected for Site Visits: 

Table 7: NTSB Air Ambulance Accident Information, 1998 through 2005: 

Figures: 

Figure 1: Air Ambulance Helicopter: 

Figure 2: Helicopter Air Ambulance Service Locations: 

Figure 3: Air Ambulance Scene Response Flight Legs: 

Figure 4: Annual Air Ambulance Bases and Aircraft, 2003 to 2005: 

Figure 5: Number of Hospital-Based and Airport and Helipad Air 
Ambulance Bases, 2003 to 2005: 

Figure 6: Total Air Ambulance Accidents, 1998 to 2005: 

Figure 7: Time of Day of Air Ambulance Fatal and Nonfatal Accidents, 
1998 to 2005: 

Figure 8: Percentage of Air Ambulance and Other Helicopter Accidents 
Associated with Adverse Weather, 1998 to 2005: 

Abbreviations: 

AAMS: Association of Air Medical Services: 
AMPA: Air Medical Physician Association: 
AMSAC: Air Medical Safety Advisory Council: 
CAMTS: Commission on the Accreditation of Medical Transport Systems: 
CUBRC: Calspan-University of Buffalo Research Center: 
DOT: Department of Transportation: 
FAA: Federal Aviation Administration: 
FARE: Foundation for Air Medical Research and Education: 
GAATAA: General Aviation and Air Taxi Activity and Avionics survey: 
HEMS: Helicopter Emergency Medical Services: 
NTSB: National Transportation Safety Board: 
PHI: Petroleum Helicopters International: 
SEP: Surveillance and Evaluation Program: 

United States Government Accountability Office: 
Washington, DC 20548: 

February 21, 2007: 

The Honorable Jerry F. Costello: 
Chairman: 
Subcommittee on Aviation: 
Committee on Transportation and Infrastructure: 
House of Representatives: 

Dear Mr. Chairman: 

The image of a helicopter air ambulance landing at a hospital or on the 
side of a highway--a familiar sight on television news--is an 
indication of the degree to which such ambulances are now a part of the 
nation's medical system. Air ambulance transportation is widely 
regarded as having a beneficial impact on improving the chances of 
survival and recovery for trauma victims and other critical patients, 
particularly in rural areas that lack readily accessible advanced-care 
facilities and medical specialists. Medical theory and practice hold 
that providing critically injured patients with surgical intervention 
within the first hour after injury occurs--a time period referred to by 
some as the "golden hour" --can significantly improve chances for 
survival and recovery. Air ambulance helicopters, with their ability to 
land at accident sites and quickly shuttle to landing areas at or near 
hospitals, can reduce transport times for many patients. 

Figure 1: Air Ambulance Helicopter: 

[See PDF for Image] 

Source: Clare McLean 2006. 

[End of section] 

Air ambulance operations, however, can also be risky. Challenging 
flight conditions such as flying at night and into unfamiliar landing 
sites, within the critical window for medical intervention, makes these 
flights inherently more risky than those conducted by other 
helicopters. In recent years, the number of air ambulance accidents has 
led to increased scrutiny of the industry by government agencies, the 
public, the media, and the industry itself. In addition, the Federal 
Aviation Administration (FAA), the federal agency responsible for 
providing safety oversight, has been asked by the National 
Transportation Safety Board (NTSB) and others to issue more stringent 
safety requirements for the industry. 

In response to your request, we examined the safety issues facing the 
industry and FAA's safety oversight. Specifically, we addressed the 
following questions: (1) What have been the recent trends in the air 
ambulance industry with regard to size, composition, and safety record? 
(2) What challenges does FAA face in providing safety oversight of the 
air ambulance industry? and (3) What efforts does FAA have under way to 
address any oversight challenges, and what is known about the effects 
of these efforts? To address these questions, we analyzed NTSB, FAA, 
and industry data; conducted an extensive literature review; and 
interviewed FAA and NTSB officials, as well as industry experts and 
representatives from key industry associations and air ambulance 
operators. In addition, we conducted site visits to five states that 
had multiple air ambulance operators with a diversity of business 
models operating in proximity to one another. During these site visits, 
we interviewed representatives of air ambulance service providers and 
officials from local FAA flight standards district offices. We also 
visited operator facilities and observed a number of elements of 
operations. This report focuses on the aviation safety aspects of 
commercial helicopter air ambulances; the scope of our study did not 
include analysis of the appropriateness of associated costs, payments, 
or medical utilization of air ambulance transportation. We conducted 
our review from April 2006 through January 2007 in accordance with 
generally accepted government auditing standards. More details 
regarding our scope and methodology can be found in appendix I. 

Results in Brief: 

The air ambulance industry has experienced recent growth, primarily in 
stand-alone (independent) operations, and an increase in the number of 
accidents, resulting in increased efforts to make safety-related 
improvements. There is limited or incomplete data available on basic 
aspects of the industry, including the number of air ambulance 
helicopters and the number of hours flown by air ambulances. Although 
data limitations preclude a complete understanding of the industry, 
including its growth, available data for 2003 to 2005 show the number 
of helicopters involved exclusively in air ambulance operations 
increased 38 percent (from 545 to 753), while the number of locations 
from which they operate grew by 30 percent (from 472 to 614). 
Similarly, although data are not available on the number of stand-alone 
and hospital-based operators, most of the growth in operating locations 
since 2003 has been in airports and stand-alone helipads rather than 
hospital-based locations. This is a strong indication of the movement 
toward stand-alone operations. Industry sources indicate that this 
growth has produced more competition in certain areas and potentially 
led to such unsafe practices as "helicopter shopping"--a continued 
search for air ambulance service by emergency medical service 
dispatchers until an operator agrees to accept a flight. We identified 
a total of 89 air ambulance accidents from 1998 to 2005 that resulted 
in 75 fatalities and 31 serious injuries. These 89 accidents represent 
nearly 40 percent of the total air ambulance accidents since 1972. The 
annual number of accidents involving air ambulances tripled from 6 to 
18 from 1998 to 2003 but has since declined to 12 and 11 in 2004 and 
2005, respectively. This number remains above the levels of the 1980s, 
but the drop in the past two years may reflect increased safety efforts 
by the industry. These efforts include the creation of a study group 
that recommends practices for operators to follow and the 
implementation of various training programs. However, the lack of data 
about the number of flights or flight hours precludes the calculation 
of the industry's accident rate, making it difficult to determine 
whether the industry is becoming more or less safe. 

FAA's main challenge in providing safety oversight for air ambulances 
is that its oversight approach is not geared toward air ambulance 
helicopter operations, but rather to other segments of the aviation 
industry that do not share many of the same operating characteristics 
and risks. To oversee air ambulance operations, FAA uses a set of 
regulations--Part 135--that it also uses to oversee air taxi services 
and other on-demand operations. Unlike these other operators, air 
ambulances provide urgent medical transport often by flying to remote 
scenes, landing at ad-hoc prepared sites, and operating at all times of 
day in a variety of weather conditions. Further, air ambulance 
transport can involve emergency medical service dispatchers, crew 
members, and others, underscoring the role of human factors before and 
during a transport. Available data confirm that air ambulance accidents 
are often related to their unique operating environment. For example, 
fatal crashes involving air ambulances occur most often at night, and 
air ambulance helicopters are four times more likely to have weather- 
related crashes than helicopters used by other operators flying under 
the same set of regulations. Our work showed that FAA inspectors may 
not have the necessary expertise to certify some safety technology for 
implementation by air ambulance operators. Inspectors also have limited 
opportunities to review the air ambulance operations at the many remote 
base stations of large operators due to a lack of time and resources. 
The broad nature of Part 135 regulations further inhibits FAA safety 
oversight, as requirements within these regulations may not fully 
address the risks inherent to air ambulance operations. 

FAA has a number of efforts under way to strengthen its oversight of 
air ambulance operators, but it has not developed ways to evaluate the 
effectiveness of these efforts. FAA's efforts include establishing a 
task force to review air ambulance accidents, conducting various 
meetings with industry officials, and devoting additional staff 
resources to overseeing the largest operators. Another effort involves 
issuing guidance to FAA inspectors and air ambulance operators to 
enhance air ambulance safety. This new guidance has covered such 
matters as reviewing pilots' and mechanics' adherence to procedures, 
promoting risk management, and emphasizing certain aspects of safety. 
Although the guidance has been voluntary to date, FAA has not ruled out 
future regulatory action. While FAA inspectors are required to promote 
the safety actions outlined in the guidance to air ambulance operators, 
FAA has no plans for tracking the degree to which operators are 
voluntarily implementing the guidance. FAA's ability to assess its 
efforts is limited not only because it does not know the extent of 
operators' implementation of the guidance but also because it cannot 
accurately measure basic trends in the industry, such as changes in the 
accident rate. Measuring these trends requires reliable data about 
actual flight hours--data FAA does not currently have. Without this 
data, FAA cannot know if it is targeting the appropriate amount of 
agency resources to air ambulance oversight or whether its efforts are 
achieving their intended results. Our discussions with air ambulance 
operators indicated that flight-hour information is available and that 
operators are willing to share it with FAA. 

To help FAA monitor industry growth trends, accident rates, and 
operator implementation of FAA guidance, we are recommending that the 
Secretary of Transportation direct the Administrator of FAA to (1) 
identify the data necessary to better understand the air ambulance 
industry and develop a systematic approach for gathering and using this 
data, and (2) collect information to evaluate the effectiveness of 
voluntary FAA guidance. We provided the Department of Transportation 
(DOT) and NTSB with a draft copy of this report for their review and 
comment. DOT agreed with our findings and conclusions, and agreed to 
consider our recommendations. NTSB agreed with our findings, 
conclusions, and recommendations. Both agencies provided technical 
comments, which were incorporated, as appropriate. We also provided the 
Association of Air Medical Services (AAMS) with a draft of this report 
to review, and AAMS agreed with our recommendations. 

Background: 

Air Ambulance Operations Perform Various Duties and Take Several Forms: 

Air ambulance use in the United States began on a small scale in the 
early 1970s, after use of air evacuation for wounded troops was 
demonstrated to be an effective means of reducing combat mortality both 
in the Korean and Vietnam wars. Air ambulances currently perform a 
number of functions. Although most people may associate an air 
ambulance with an on-scene response to an accident, the majority of 
transports--about 54 percent--are from hospital to hospital. On-scene 
responses make up another 33 percent, and the remaining 13 percent of 
transports include organ, medical supply, and specialty medical team 
transports. Air ambulances are of two main types--helicopters and fixed-
wing aircraft. These two types of aircraft are generally used on 
different types of missions, with helicopters providing on-scene 
responses and much of the shorter distance hospital-to-hospital 
transport, and fixed-wing aircraft providing longer hospital-to- 
hospital transports between airports. Helicopter air ambulances make up 
more than 80 percent of the air ambulance fleet and, unlike fixed-wing 
aircraft, do not always operate under the direction of FAA air traffic 
controllers. This report concentrates on safety oversight issues 
related to helicopter air ambulances. 

Air ambulances are an integrated part of emergency medical systems 
throughout the United States, and the market is dominated by a few 
large operators. For example, it has been estimated that the top seven 
operators operate nearly 80 percent of helicopter air ambulances. 
Before commencing air ambulance flights, an operating certificate must 
be obtained from FAA.[Footnote 1] FAA issues the certificate after 
determining that an operator's manuals, aircraft, facilities, and 
personnel meet federal safety standards. FAA subsequently monitors the 
operator, primarily through safety inspections, to ensure that an 
operator continues to meet the terms of its certificate. Air ambulance 
operators often operate multiple air ambulance programs from a variety 
of satellite base stations at hospitals, airports, or helipads in other 
locations.[Footnote 2] Figure 2 shows base locations of helicopter air 
ambulance services that perform on-scene transports. 

Figure 2: Helicopter Air Ambulance Service Locations: 

[See PDF for Image] 

Sources: Atlas and Database of Air Medical Services (ADAMS); compiled 
by CUBRC's Center for Transportation Injury Research (CenTIR) in 
alliance with the Association of Air Medical Services (AAMS) with 
support from the Federal Highway Administration (FHWA) and National 
Highway Traffic Safety Administration (NHTSA); composite map by GAO. 

[End of figure] 

Air ambulance operations can take many different forms but are 
generally one of two types--hospital-based or stand-alone:[Footnote 3] 

* In a hospital-based model, a hospital typically provides the medical 
services and staff and contracts with an aviation services provider for 
pilots, mechanics, and aircraft. The aviation services provider also 
holds the FAA operating certificate. In the hospital-based model, the 
hospital is responsible for billing the patient and pays the operator 
on a fixed monthly and variable hourly rate for services 
provided.[Footnote 4] 

* In a stand-alone (independent) provider model, an independent 
operator sets up a base in a community and serves various facilities 
and localities. Typically, the operator holds the FAA operating 
certificate and employs both the medical and flight crews, or contracts 
with an aviation services provider for all of these things. Compared 
with the hospital-based model, this approach carries more financial 
risk for the operator because revenues depend solely on patient 
flights. 

Table 1 illustrates the differences in these business models by 
providing information on two of the operators we visited. 

Table 1: Examples of Independent and Hospital-Based Operators: 

Characteristic: Program; 
Independent operator: Petroleum Helicopters International Air Medical; 
Hospital-based operator: Teddy Bear Transport; Cook Children's Medical 
Center. 

Characteristic: Holder and location of FAA operating certificate; 
Independent operator: Petroleum Helicopters International (PHI); 
Lafayette, Louisiana; Hospital-based operator: CJ Systems; Harrisburg, 
Pennsylvania. 

Characteristic: Number of bases; 
Independent operator: 49; 
Hospital- based operator: 1. 

Characteristic: Location of bases; 
Independent operator: 14 states; 
Hospital-based operator: Fort Worth, Texas. 

Characteristic: Number of helicopters; 
Independent operator: 224; 
Hospital-based operator: 1. 

Characteristic: Tax status; 
Independent operator: For profit; 
Hospital- based operator: Nonprofit. 

Characteristic: Flight crew employer; 
Independent operator: PHI; 
Hospital-based operator: CJ Systems. 

Characteristic: Medical crew employer; 
Independent operator: PHI; 
Hospital-based operator: Cook Children's Medical Center. 

Characteristic: Revenue sources; 
Independent operator: Per-flight basis; 
Hospital-based operator: Patient flights, hospital admission. 

Characteristic: Mission profile; 
Independent operator: 50% on-scene 50% hospital-to-hospital; 
Hospital-based operator: 100% hospital-to- hospital. 

Source: GAO. 

[End of table] 

Government and Industry Both Play a Role in Air Ambulance Oversight: 

All levels of the government and the air ambulance industry play 
significant roles in air ambulance oversight. FAA has oversight over 
commercial aviation activities performed by air carrier operators, a 
group that includes operators of air ambulances. FAA's air ambulance 
safety oversight is carried out by inspectors located in FAA field 
offices throughout the United States that are a part of nine regional 
offices. For each operating certificate, FAA puts together a team of 
inspectors (also known as the certificate management team), led by 
principal inspectors, who focus on one of three disciplines: avionics, 
maintenance, or operations. Since 1985, FAA has used the National 
Flight Standards Work Program Guidelines, its traditional inspection 
program for airlines, as a primary means of ensuring air ambulance 
operator compliance with safety regulations. Under the National Flight 
Standards Work Program Guidelines, an FAA committee identifies an 
annual minimum set of required inspections that are to be undertaken. 
In addition, inspectors determine annual sets of planned inspections 
based on their knowledge and experience with the particular operator 
they oversee. When violations of statutory and regulatory requirements 
are identified through inspections, FAA has a variety of enforcement 
tools that it may use to respond to the violations, including 
administrative and legal sanctions. 

Under FAA regulation, most air ambulances operate under rules specified 
in Part 135 of Title 14 of the Code of Federal Regulations.[Footnote 5] 
However, pilots may operate under different standards, depending on 
whether they are carrying patients. Without patients or passengers on 
board, pilots may operate under rules specified in Part 91 of Title 
14.[Footnote 6] These flights are considered "positioning" flights and 
occur when flying to an accident scene or after having transported the 
patient to the hospital or other destination. Medical personnel are 
often on board for these flights, as they are considered part of the 
crew rather than passengers. With patients on board, pilots are 
required to operate under Part 135 rules. 

Part 91 and Part 135 flight rules differ significantly in two key 
areas--(1) weather and visibility minimums and (2) rest requirements-- 
with Part 135 requirements being more stringent. Under Part 91, the 
basic weather minimum requirements for visual flight rules only state 
that helicopters operate "clear of clouds" if flying under 1,200 feet 
in uncontrolled (Class G) airspace and that the pilot must have 
"adequate opportunity to see any air traffic or obstruction in time to 
avoid a collision." This does not impose any specific flight visibility 
distance on the pilot. In contrast, Part 135 requires that helicopter 
operators flying under 1,200 feet have visibility of at least a half 
mile during the day and at least one mile at night. This is the only 
situation in which Part 91 weather minimums for visual flight rules are 
lower than Part 135. Additionally, Part 135 requires that all 
helicopter operators have visual surface reference during the day and 
visual surface light reference at night. The other key difference 
between Part 91 and Part 135 is the imposition of rest requirements on 
pilots. Part 91 neither contains requirements for pilots to rest prior 
to their flights nor prescribes a maximum duty time. Part 135, on the 
other hand, requires helicopter pilots conducting emergency medical 
operations to have adequate rest periods before and after their 
flights, and it also contains restrictions on the number of consecutive 
hours that pilots may fly.[Footnote 7] 

In many air ambulance trips, part of the trip may involve Part 135 
rules, while another part may involve Part 91 rules. Scene response 
missions for air ambulance helicopters frequently have three legs: the 
flight en route to the accident scene, the transport of the patient to 
the hospital, and the repositioning of the helicopter back to its base 
(see fig. 3). Of these three flight legs, only the leg during which 
patients or other passengers (medical crew are not considered 
passengers) are on board must be flown under Part 135 flight rules. 
Because air ambulance flights without patients or passengers could be 
flown under Part 91 requirements, there may be more than twice as many 
flights taking place under Part 91 compared with Part 135. 

Figure 3: Air Ambulance Scene Response Flight Legs: 

[See PDF for Image] 

Source: GAO. 

[End of figure] 

NTSB also plays a role in monitoring the safety issues related to the 
air ambulance industry. As an independent federal agency charged by 
Congress with investigating every aviation accident in the United 
States, NTSB conducts investigations of air ambulance accidents and 
develops factual reports containing determinations of probable cause 
for these accidents. In January 2006, NTSB published a special report 
focusing on emergency air medical operations, which included an 
identification of recurring safety issues in air ambulance accidents 
and subsequent recommendations for improving safety in the 
industry.[Footnote 8] Additionally, in 1988, in response to an 
increased number of accidents in the mid-1980s, NTSB published a safety 
study that examined similar issues. The study contained 19 safety 
recommendations to FAA and others, which have since been addressed, 
according to NTSB.[Footnote 9] 

Some state and local governments play a role in oversight of the air 
ambulance industry, as well. The federal Airline Deregulation Act of 
1978 explicitly prohibits states from regulating the price, route, or 
service of an air carrier; therefore, oversight at the state or local 
levels is generally limited to the medical care and equipment of air 
ambulance services. The extent of this oversight, however, varies by 
state and locality. Some states have not developed a regulatory 
framework to oversee the medical care side of air ambulance services. 
Other states do provide some oversight; California, for example, 
delegates authority to local governments for emergency medical service 
coordination and requires air ambulance providers to obtain a permit 
from any county in which they routinely operate, irrespective of where 
the provider is based. Still others, such as Maryland, Texas, 
Washington, and Arizona, require state licensure of all air ambulance 
service providers. 

The industry also plays a role in its own oversight. One such industry- 
driven activity is the accreditation offered by the Commission on 
Accreditation of Medical Transport Systems (CAMTS), a 16-member 
organization that provides voluntary accreditation for medical 
transport systems, including air ambulances. Over 120 air ambulance 
providers have earned CAMTS accreditation since its inception in 1991, 
and five states have made CAMTS accreditation mandatory for all air 
ambulance providers wishing to operate within their jurisdiction. CAMTS 
places an overarching emphasis on patient care and transport safety, 
with specific accreditation standards focusing on aircraft maintenance 
and use as well as the medical, communications, and management aspects 
of operation. Industry trade groups also play an informal role in 
oversight. Industry groups, including the Association of Air Medical 
Services, Helicopter Association International, the Air Medical 
Physician's Association, and the National EMS Pilots Association, 
devote much of their attention to information sharing regarding 
operational challenges and best practices within the industry, 
organizing conferences, and publishing white papers in order to place a 
continued emphasis on safety. 

Increase in Size and Safety-Related Concerns Mark Industry's Recent 
Years: 

Since 1998, the air ambulance industry has been characterized by 
growth, an increased number of accidents, and various efforts to make 
operations safer. Growth, according to industry officials and the 
limited data available, has occurred mainly in stand-alone for-profit 
operations rather than nonprofit hospital-based programs. For much of 
this expansion period, the number of accidents also rose, peaking at 18 
in 2003. During the 8-year period we examined (1998 through 2005), 89 
air ambulance accidents occurred, but a lack of data about the number 
of flights or hours flown prohibits us from calculating whether the 
rate of accidents has increased, decreased, or remained the same over 
this period. The 89 accidents represent nearly 40 percent of all air 
ambulance industry accidents since 1972. Thirty-one of these accidents 
resulted in fatalities, and 9 others resulted in serious injuries to 
people on board. To address these developments, the air ambulance 
industry has been encouraging greater safety among its operators 
through such steps as conferences, additional training, and safety 
awareness programs. 

Data Limitations Preclude Complete Understanding of Industry's Growth: 

Although industry experts and observers acknowledge the recent growth 
of the air ambulance industry, the available data make it difficult to 
gauge clearly the extent of the growth. Several years of data on two 
indicators--number of aircraft and number of operating locations--are 
available in a database maintained by the Calspan-University of Buffalo 
Research Center (CUBRC) in alliance with AAMS.[Footnote 10] For 2003, 
the first year of the database, association members reported a total of 
545 helicopters stationed at 472 bases (airports, hospitals, and 
helipads).[Footnote 11] By 2005, the number of helicopters listed in 
the database had grown to 753, an increase of 38 percent, and the 
number of bases had grown to 614, an increase of 30 percent (see fig. 
4). A database official said that to some degree, the increase reflects 
a broadening of the criteria for inclusion as well as better reporting 
since the database was first established, but the increase also 
reflected actual growth, which is similar to anecdotal information 
relayed to us by air ambulance operators. For example, officials from 
two large operators told us that their companies had added bases or 
aircraft in the last few years. FAA maintains records of the number of 
air ambulance operator aircraft currently in operation but does not 
distinguish a company's dedicated air medical aircraft from its other 
aircraft. FAA does estimate the number of air medical aircraft based on 
its annual General Aviation and Air Taxi Activity and Avionics (GAATAA) 
survey, and according to available estimates, there were 435 air 
medical helicopters in 1999 and 741 in 2004, an increase of 70 
percent.[Footnote 12] It is difficult to regard these estimates as 
reliable, however, because the survey is based on a sample of aircraft 
owners and has historically experienced low response rates. 

Figure 4: Annual Air Ambulance Bases and Aircraft, 2003 to 2005: 

[See PDF for Image] 

Source: Association of Air Medical Services, Atlas and Database of Air 
Medical Services. 

[End of figure] 

Data are less available on whether this increase in aircraft translates 
into an increased number of operating hours. FAA does not collect 
flight-hour data from air ambulance operators. Unlike scheduled air 
carriers, which are required to report flight hours, air ambulance 
operators and other types of on-demand operations regulated under Part 
135 are not required to report flight activity data to FAA or 
DOT.[Footnote 13] FAA does develop estimates of these flight hours, 
using responses to its annual GAATAA survey. FAA estimated that air 
ambulances amassed about 900,000 flight hours annually from 1999 to 
2003 and that the number of flight hours increased to 1.6 million in 
2004. However, as noted, the reliability of these estimates is 
questionable, given various shortcomings with the GAATAA 
survey.[Footnote 14] Other studies have shown flight-hour estimates 
that are much lower than FAA estimates. For example, a study sponsored 
by the Air Medical Physician Association (AMPA) has also estimated 
annual flight hours for the air medical industry. To determine flight 
hours, the study's authors posted a survey on the Flightweb listserve 
and surveyed five of the largest air medical operators--as well as 
information listed in the AAMS membership directory and the Directory 
of Air Medical Programs, published in AirMed--to determine the number 
of programs and helicopters.[Footnote 15] To determine the number of 
flight hours, the authors multiplied the average flight hours per 
program by the total number of programs identified in each year. As a 
result, the AMPA study estimated that the total number of air medical 
flight hours grew from 187,216 in 1998 to 217,584 in 2001, an increase 
of 16 percent. FAA estimates were considerably higher for this period. 
For example, for 2001, FAA estimated a total of 1 million air medical 
flight hours. 

Some other operations-related indicators are available, and they point 
to an increase in activity. The 2002 AMPA study also estimated that the 
total number of patients flown in air ambulances rose from 174,501 in 
1998 to 203,772 in 2001, an increase of 17 percent. The study's authors 
obtained these estimates by multiplying the number of air medical 
programs by the average number of patients transported each year. Data 
maintained by the Department of Health and Human Services' Centers for 
Medicare and Medicaid Services indicate that the number of air 
ambulance trips reimbursed by Medicare increased 24 percent, from 1.65 
transports per 1,000 beneficiaries in 2001 to 2.04 transports per 1,000 
beneficiaries in 2004. Finally, two recent studies by government 
agencies, including the Congressional Research Service and FAA, 
acknowledged the industry's growth.[Footnote 16] However, these 
studies, like our own, did not find a fully comprehensive indicator of 
this growth. 

One other potential indicator of growth is the number of air ambulance 
operators, but we were unable to find data showing the change in 
operators over a several-year period. FAA maintains information about 
the air ambulance operators it oversees, but only on those currently in 
operation. As such, there was no way to determine how the number of 
operators had changed over time. FAA data indicate that as of July 31, 
2006, there were a total of 76 air ambulance operators. The number of 
operators is considerably lower than the number of aircraft and bases. 
This is because some operators have large fleets of aircraft and 
operate from many bases. For example, Air Methods, the largest air 
medical operator, operates 208 helicopters out of 96 bases. Government 
and industry officials and operators we spoke with indicated that 
industry consolidation was the current trend. 

Growth Is Primarily in Stand-Alone Businesses and Has Led to Increased 
Competition in Some Locales: 

We did not find any data on the distribution of business models within 
the air ambulance industry, but the consensus that emerged from the 
industry officials we spoke with and the information we reviewed was 
that growth has occurred mainly in the stand-alone (independent) 
provider business model. For example, a 2006 public policy paper by the 
Foundation for Air Medical Research & Education (FARE)[Footnote 17] 
observed that many air medical services "had become independent, 
community based resources." Similarly, an FAA research paper published 
in September 2005 noted that "the fastest growing segment of the [air 
medical] industry is the independent provider." In our interviews with 
government and industry officials, there was general agreement that the 
independent provider model has grown more than the traditional hospital-
based model. 

Additional support for this view can be seen in the types of operating 
bases that are growing most rapidly--airport and helipad bases, which 
are the typical bases of stand-alone operators. According to the Atlas 
and Database of Air Medical Services, the total number of stand-alone 
bases increased more than hospital bases from 2003 to 2005 (see fig. 
5). In 2003, the number of bases reported by AAMS members was about 
equally divided between hospital bases and airport and helipad bases. 
By 2005, the number of hospital bases had increased by 6 percent (from 
234 to 249), while the number of airport and helipad bases had 
increased by 53 percent (from 238 to 365). 

Figure 5: Number of Hospital-Based and Airport and Helipad Air 
Ambulance Bases, 2003 to 2005: 

[See PDF for Image] 

Source: Association of Air Medical Services, Atlas and Database of Air 
Medical Services. 

[End of figure] 

The growth in the stand-alone business model has been influenced by the 
potential for profit making, according to the officials we interviewed 
and others who have studied the industry. The influencing factor they 
most often cited was the 1997 mandate for the development of a Medicare 
fee schedule for ambulance transports.[Footnote 18] Officials we spoke 
with and literature we reviewed cited the implementation of the fee 
schedule as a factor in the increase in stand-alone services. The fee 
schedule was implemented gradually starting in 2002, and since January 
2006, 100 percent of payments for air ambulance services have been made 
under the fee schedule. Prior to 2002, all ambulance service 
reimbursements by Medicare were based on the type of provider. Hospital-
based providers were reimbursed based on their reasonable costs, while 
independent providers were reimbursed based on reasonable charges. 
These payment patterns resulted in wide variation in payment rates for 
the same service. In its final rule on the fee schedule published in 
the Federal Register on February 27, 2002, the Centers for Medicare and 
Medicaid Services anticipated that the fee schedule would redistribute 
income from ground to air ambulance services and from hospital-based to 
independent operators. 

This potential for higher and more certain revenues has, in the opinion 
of many of our sources, increased competition in certain areas. The 
Phoenix and Dallas/Fort Worth areas were cited as examples of locales 
where the presence of a large number of air ambulance operators 
intensifies competition. One industry official wrote that there were 
more air medical helicopters in Phoenix than in all of Canada.[Footnote 
19] Another noted that the Dallas/Fort Worth area had been home to only 
one operator for many years, but by mid-2006 it had eight air ambulance 
operators. 

Increased competition, according to industry experts, can also bring 
potentially unsafe practices. Although we were unable to determine how 
widespread these activities are, experts cited the potential for such 
practices, including the following: 

* Helicopter shopping: FAA defines this as the practice of calling, in 
sequence, various operators until an operator agrees to take a flight 
assignment, without sharing with subsequent operators the reasons the 
flight was declined by previously called operators. This practice can 
lead to an unsafe condition in which an operator initiates a flight 
that it may have declined if it had been aware of all of the facts 
surrounding the assignment.[Footnote 20] For example, in July 2004, a 
medical helicopter collided with trees shortly after takeoff, killing 
the pilot, flight nurse, flight paramedic, and patient. Three other air 
ambulance operators had previously turned down this same flight, 
including one who had attempted it but was forced to return due to fog. 
The pilot during the accident, however, was not informed by emergency 
medical service dispatchers that other pilots had declined the flight 
due to the weather conditions. According to NTSB, inadequate dispatch 
information contributed to the accident. 

* Call jumping: Industry officials reported that call jumping occurs 
when an air ambulance operator responds to a scene to which that 
operator was not dispatched or when multiple operators are summoned to 
an accident scene. This situation is potentially dangerous because the 
aircraft are all operating in the same uncontrolled airspace--often 
during nighttime or in marginal weather conditions--increasing the risk 
of a midair collision or other accident. The term "call jumping" 
originated in the 1970s when some ground ambulance services were 
involved in a similar practice. 

* Inappropriate use of air medical aircraft: One industry official has 
posited that air medical helicopter use may be excessive, unsafe, and 
not beneficial for most patients, citing recent studies that conclude 
few air transport patients benefited significantly over patients 
transported by ground and the recent increase in the number of air 
medical accidents. Other studies have disagreed with this position, 
citing air ambulances' impact on reductions in mortality by quickly 
transporting critically injured patients. 

Increase in Number of Accidents Has Led to Greater Industry Focus on 
Safety-Related Activities: 

From 1998 through 2005, the air ambulance industry averaged 11 
accidents per year, according to NTSB data.[Footnote 21] The annual 
number of air ambulance accidents increased from 6 in 1998 to a high of 
18 in 2003, then receded to 12 in 2004 and 11 in 2005 (see fig. 6). Of 
the 89 total accidents from 1998 to 2005, 31 accidents resulted in the 
deaths of 75 people.[Footnote 22] Another nine accidents resulted in 
serious injuries to passengers or crew. In 2003, the peak year for 
accidents in our review period, there were 4 accidents with fatalities 
and 1 with serious injuries. The remaining 2003 accidents had either 
minor injuries (4) or no injuries (9). 

Figure 6: Total Air Ambulance Accidents, 1998 to 2005: 

[See PDF for Image] 

Source: GAO analysis of NTSB data. 

[End of figure] 

The drop in the number of accidents in 2004 and 2005 came as the 
industry undertook a series of steps designed to increase safety 
awareness, discussed in further detail below. While this drop is a 
favorable development relative to the number of accidents in 2003, the 
numbers of accidents in 2004 and 2005 still closely match the overall 
average for the period. In addition, the annual average of 11 accidents 
for the 8-year period is higher than in previous years. Given the 
apparent growth in the industry, an increase in the number of accidents 
may not indicate that the industry has, on the whole, a poorer safety 
record during our review period than in previous years. More 
specifically, without actual data on the number of hours flown (data 
that FAA does not gather at present but attempts to estimate), no 
accident rate can be accurately calculated, eliminating the possibility 
of determining whether the industry is becoming safer or more 
dangerous. 

The air ambulance industry's response to the higher number of accidents 
has taken a variety of forms. These initiatives include efforts aimed 
at flight-hour data collection, research into accident causes, 
training, and sharing of recommended practices. For example, in 2005, 
the Pilot Study Safety Group--with the support of FARE--sponsored a Web-
based survey of air medical pilots in which pilots were asked about 
their primary safety concerns and what equipment they need to fly more 
safely. As a result of the survey, the study group is recommending (1) 
that a gold standard for air medical operators be established that 
would include annual crew resource management[Footnote 23] training for 
all personnel, (2) flight simulation training for all pilots that 
includes motion and instrument meteorological conditions, and (3) night 
vision aid or mission-oriented unaided night flight training for all 
crew members. Table 2 highlights some of the other industry initiatives 
we have identified. Although the impact of these initiatives on 
reducing accidents has not been assessed, the decrease in the annual 
number of industry accidents since 2003 may be an indicator that the 
initiatives are having some effect. This seemed to be the case in the 
mid-1980s when a reversal of the increasing accident trend occurred 
after a combination of industry and FAA efforts. 

Table 2: Examples of Air Ambulance Industry Initiatives to Address 
Safety Concerns: 

Year: 1999; 
Organization: AAMS; 
Initiative: Distributed a safety poster to its members and held "Safety 
Day" at the Air Medical Transport Conference to focus on program 
safety. 

Year: 2000; 
Organization: Air Medical Safety Advisory Council (AMSAC); 
Initiative: Develops recommended practices for the industry. 

Year: 2001/2002; 
Organization: AMSAC; 
Initiative: Implemented "Train the Trainer" Air Medical Resource 
Management programs. 

Year: 2002; 
Organization: Air Medical Physicians Association; 
Initiative: Published "A Safety Review and Risk Assessment in Air 
Medical Transport.". 

Year: 2005; 
Organization: AAMS; 
Initiative: Adopted "Vision Zero," the air medical community's program 
to promote safety awareness. 

Year: 2006; 
Organization: AAMS; 
Initiative: Sponsors the Flight Operational Database for Air Medical 
Services--an effort to collect flight and flight-hour data for air 
medical operators. 

Year: 2006; 
Organization: Air & Surface Transport Nurses Association; 
Initiative: Published a position paper on transport nurse safety in the 
transport environment. 

Source: GAO. 

[End of table] 

FAA Safety Oversight Does Not Fully Address Industry's Operational 
Risks: 

FAA resources, safety inspections, and regulations are tailored to 
oversee a wide range of aviation activities and do not address many of 
the operational risks facing air ambulance operators; therefore, FAA 
faces challenges in providing safety oversight of the air ambulance 
industry. Compared with other operators, air ambulance transports are 
subject to greater risks, because these flights often occur during 
nighttime, in adverse weather, and to remote sites in order to provide 
medical attention. Operational control often occurs away from 
headquarters, and many individuals and systems are involved in 
coordinating these flights, underscoring the role of human judgment and 
risk-management protocols. Available data demonstrate the risks 
inherent to the flight environment and stemming from poor judgment. For 
example, NTSB data show that more than one-third of all fatal air 
ambulance helicopter accidents involved weather. FAA inspections and 
resources are not tailored to the air ambulance industry, as few 
inspectors have the necessary qualifications to certify operators' use 
of available safety technology, and inspections of satellite bases by 
the assigned inspectors are infrequent. In addition, the requirements 
within Part 135 regulations are broad and may not fully address the 
dangers of poor decision making and the propensity for flights to occur 
at night or to remote sites. 

Air Ambulance Operations Face Risks Different from Those Faced by Other 
Operations Subject to Part 135 Regulations: 

Under Part 135 rules, FAA regulates a wide variety of aviation 
operations, including both "scheduled" (commuter flights with fewer 
than 10 seats) and "nonscheduled" (on-demand air carriers, including 
air ambulances).[Footnote 24] Part 135 operations can include such 
flights as small package cargo transport, business and personal 
domestic and international transport, and shuttle services to 
industrial job locations, such as oil platforms at sea. While these 
operators may provide services in a variety of conditions, their 
operations are generally characterized by smaller geographic operating 
areas and more uniformity across their bases compared with that of air 
ambulance operators. For example, these operators generally do not have 
many remote bases and they take off and land at established landing 
zones. 

Operationally, air ambulance operations are distinct from these other 
types of operations in several key ways: 

* Operations are subject to greater risks. Air ambulance helicopters 
are used to quickly transport individuals requiring urgent or emergency 
medical attention at all hours of the day, and crews face greater risks 
from flying at night, in marginal weather conditions, and to and from 
remote sites. In "scene work" (picking up a sick or injured patient at 
an off-airport/heliport site), the landing zone is a makeshift site to 
which the pilot has likely never been. Such operations, coupled with 
low visibility, can contribute to severe outcomes. Available data tend 
to confirm that the air ambulance transports face greater risks than 
other types of helicopter transports. NTSB data of helicopter accidents 
occurring between 1998 and 2005 show that factors related to flight 
environment (such as light, weather, and terrain) underlie 70 percent 
of all air ambulance accidents, compared with 40 percent of accidents 
for other helicopter accidents.[Footnote 25] Data on the flight 
environment of air ambulance accidents indicate a number of risks, 
including the following: 

* Nighttime operations. Nighttime accidents for air ambulance 
helicopters were more prevalent than for other helicopter operations, 
and air ambulance accidents tended to be more severe when they occurred 
at night than during the day. More than half of all air ambulance 
helicopter accidents took place at night, compared with 9 percent of 
non-air-ambulance helicopter accidents. Nighttime accidents also carry 
a greater tendency to be fatal. NTSB data indicate that from 1998 to 
2005, air ambulance accidents that occurred at night were almost four 
times more likely to result in fatalities than those occurring during 
the day--51 percent versus 13 percent (see fig. 7). 

Figure 7: Time of Day of Air Ambulance Fatal and Nonfatal Accidents, 
1998 to 2005: 

[See PDF for Image] 

Source: GAO analysis of NTSB data. 

[End of figure] 

* Adverse weather. Air ambulance accidents were more often associated 
with weather conditions compared with other helicopter accidents. 
Weather conditions such as snow, gusting wind, and fog have been known 
to contribute to air ambulance accidents. While 4 percent of other 
helicopter accidents are associated with bad weather, air ambulance 
accidents were nearly four times more likely (15 percent) to be 
attributed to adverse weather (see fig. 8). NTSB data show that 
overall, more than one-third of fatal air ambulance accidents were 
attributable in part to weather. 

Figure 8: Percentage of Air Ambulance and Other Helicopter Accidents 
Associated with Adverse Weather, 1998 to 2005: 

[See PDF for Image] 

Source: GAO analysis of NTSB data. 

[End of figure] 

* Remote sites. Flying to remote sites may further expose the crew to 
other risks associated with unfamiliar topography or ad-hoc landing 
sites. Data show that accidents attributable to an in-flight collision 
with objects occurred more frequently for air ambulances than other 
helicopters. Air ambulance helicopters also can encounter difficulties 
with ad-hoc landing zones at remote sites, such as being engulfed in 
clouds of dust commonly referred to as brownouts. For example, in July 
1998 during a brownout, an air ambulance helicopter rolled over when 
the pilot lost visual contact with the ground. 

* Multiple bases located away from headquarters. FAA inspectors 
assigned to large air ambulance certificates told us that the 
dispersion of bases away from operator headquarters may result in less 
disciplined adherence to internally established risk assessment 
practices and protocols. Air ambulance bases are often dispersed away 
from headquarters, either as independent stand-alone bases or through 
contractual relationships with hospitals. In contrast, other Part 135 
helicopter operations typically are not dispersed. The dispersion of 
bases away from the certificate holders' headquarters and the location 
of bases are in part due to medical need and demand for services. For 
example, one state emergency medical services official reported that 
operators look at high accident road intersections in considering where 
to locate their bases. 

* Many individuals and systems are involved in transports. Many 
individuals and systems may be involved in coordinating air ambulance 
transports. The number and expertise of people involved in making 
decisions and passing on information about flights and flight 
conditions can increase the risk of incorrect or incomplete information 
being relayed. Multiple systems, involving both public and private 
resources, are used in determining when to relay a request, which air 
ambulance provider the request will be relayed to, and if a request 
will be accepted and completed. Emergency medical service dispatchers 
may not uniformly gather all of the information needed by air ambulance 
providers, such as weather at the landing site. Ground personnel may 
also be involved with relaying critical information about the landing 
site to the crew; but again, they may not provide critical information 
to the air ambulance operator. For example, in Parumph, Nevada, an air 
ambulance helicopter crashed while attempting to pick up a patient at a 
remote site when ground personnel incorrectly informed the helicopter 
crew that there were no wires obstructing the site. 

* Human judgment may override risk-based protocols. Human judgment can 
play a critical role in air ambulance transport, particularly given the 
risks found in the flight environment and the medical urgency. For 
example, during a dark night in June 1998 in La Gloria, Texas, a 
helicopter crashed into trees nearly 20 miles past the accident site to 
which it was headed. Attributes of the crash, as reported by NTSB, 
indicated that the pilot failed to recognize his intended destination 
and had flown past it and that the adverse weather conditions resulted 
in the pilot's loss of control from experiencing spatial 
disorientation. The pressure to complete the airlift and the pilot's 
lack of experience with flying by instruments were cited among the 
contributing factors by NTSB in its accident report. The following 
accident data highlight the prominence of poor human judgment in an 
already inherently risky line of work: 

- Ninety-four percent of air ambulance accidents between 1998 and 2005 
had at least one cause related to pilot/operational errors, while 86 
percent of non-air-ambulance accidents during the same time period had 
pilot/operational causes. 

- In total, 28 percent of air ambulance accidents between 1998 and 2005 
had at least one planning or decision-making related cause, while 19 
percent of non-air-ambulance accidents had such causes. 

Air operators rely on a number of protocols, such as operational 
control (the authority over initiating, conducting, and terminating a 
flight), risk assessment matrices, and air medical resource management 
training to help reduce the potential for poor or erroneous 
judgment.[Footnote 26] However, there are indications that in air 
ambulance operations, these protocols may be inconsistently implemented 
or followed. According to an FAA report that reviewed air ambulance 
accidents occurring from 1998 to 2004, a lack of operational control 
and poor aeronautical decision making were significant contributing 
factors to these accidents.[Footnote 27] Specifically, the report cited 
the susceptibility of crew members to external factors in decision 
making. FAA inspectors we spoke with reported that factors such as 
competition and the contractual relationship between a vendor and 
provider can result in a loss of operational control when unauthorized 
medical or other staff exert pressure over the crew to fly. Several 
trade organizations also said that the trend toward stand-alone 
providers has increased the susceptibility of operational decision 
making to financial incentives. Additionally, FAA inspectors we 
interviewed reported that the dispersion of bases away from certificate 
holder headquarters may result in less disciplined adherence to 
internally established risk assessment practices and protocols. 

FAA Inspections Framework Is Not Tailored to Risks of the Air Ambulance 
Industry: 

FAA faces challenges in providing safety oversight to the air ambulance 
industry because the existing inspections approach and resources are 
not tailored to address the specific operational aspects of air 
ambulance transports. Current FAA inspections and resources may not 
enable its staff to meet the workload, training, and travel 
requirements associated with conducting oversight activities of air 
ambulance certificates. These challenges stem from the distinctive way 
that air ambulance operators are structured, their size, use of 
emerging technology, and dispersed bases. In addition, FAA does not 
collect data that would help demonstrate how its inspections approach 
is connected to safety outcomes. These challenges are discussed in more 
detail below. 

* Size and scope of air ambulance operations. Each year, the National 
Flight Standards Work Program Guidelines sets the minimum number of FAA 
required inspections for all Part 135 operators. Although the National 
Flight Standards Work Program Guidelines outlines the minimum 
inspection requirements for all Part 135 operators, the principal 
inspectors must determine how many additional inspections might be 
necessary for adequate oversight in light of the size and risk factors 
associated with a certificate holder. In the case of large air 
ambulance operators, these additional inspections can be considerable 
due to the size and scope of the operations. For example, according to 
FAA officials, the certificate management team for one large air 
ambulance operator had 2,396 hours of required inspector surveillance 
hours for fiscal year 2006. However, the team estimates that a total of 
4,425 inspector surveillance hours will actually be needed for fiscal 
year 2006 in order to provide appropriate oversight. Additionally, 
FAA's procedures for establishing and maintaining pay grades for 
inspectors may be a contributing factor in how much attention is given 
to the oversight of large air ambulance operators. FAA assigns points 
to the inspection activities of inspectors, and these points, in turn, 
are tied to an inspector's pay. Several inspectors of air ambulance 
operators reported that the points assigned to the oversight of these 
operators are not commensurate with the risk and size of these 
operations. 

* Lack of training and qualifications to oversee use of technology. 
According to FAA inspectors and officials we spoke with, FAA has few 
inspectors who have the necessary qualifications to certify the use of 
safety technology being adopted by air ambulance operators, and FAA 
does not provide inspectors with training in emerging safety 
technology. Several of the FAA inspectors we interviewed reported not 
receiving what they felt to be the necessary training that would allow 
them to provide oversight of operators' implementation of new 
technology. This is similar to concerns we raised in a previous report 
on FAA's inspection program.[Footnote 28] Specifically, we found that 
FAA develops technical courses on an ad-hoc basis rather than part of 
an overall curriculum for each inspector specialty--such as air 
ambulance operations--because the agency has not systematically 
identified the technical skills and competencies each type of inspector 
needs to effectively perform inspections. FAA developed the Flight 
Standards Inspector Resource Program, in which inspectors with special 
expertise in a technology can assist other inspectors whose operator 
may be using such technology. For example, currently few inspectors are 
qualified to provide operator certification in night vision goggle use. 
However, several inspectors we spoke to found this program problematic, 
because of the burden it poses to the inspector that must certify the 
use of night vision goggles and continue to carry out their other 
required duties. 

* Limited oversight of base locations. While air ambulance bases and 
helicopters for any one operator are often located across the country, 
the assigned principal inspectors are based in the FAA district office 
where the operating certificate is registered and held by an operator's 
headquarters office. This may be important because operators may have 
many remote bases of operations; for example, one of the largest air 
ambulance companies has no helicopters located at the headquarters 
location. FAA principal inspectors assigned to large air ambulance 
certificates we spoke with said they did not have the travel funds or 
time to perform inspections of many remote bases. Instead, inspectors 
from local FAA offices--called geographic inspectors--assist with the 
oversight of these bases at the request of a principal 
inspector.[Footnote 29] Some FAA principal inspectors expressed little 
confidence in the quality of these inspections, however, because 
geographic inspectors may lack comprehensive knowledge of the 
operators' manuals or lack helicopter expertise. 

The challenges that FAA faces in applying its general inspections 
approach to the air ambulance industry are also evident in its 
violations and enforcement activities. Principal inspectors we spoke 
with noted that the problems they typically found with air ambulance 
operator certificates were generally tied to the maintenance of proper 
paperwork and other record keeping irregularities, and not to known 
industry safety issues such as risk management and decision making. 
This may indicate that the factors that frequently contribute to air 
ambulance accidents, such as flying at night or in adverse weather, are 
not necessarily addressed by typical FAA oversight activities, which 
focus on such things as maintenance and training. Additionally, FAA was 
unable to provide us with reliable data of FAA enforcement actions 
related specifically to helicopter air ambulances because enforcement 
data for operators do not distinguish the actions taken against 
operators' air medical operations from operators' other lines of 
business. For example, the core business of Petroleum Helicopters 
International (PHI), one of the largest air ambulance operators, 
consists of providing offshore helicopter support to oil and gas 
companies operating in the Gulf of Mexico. FAA enforcement data we 
reviewed for PHI do not specify which enforcement actions were taken 
against the company's air medical operations and its offshore 
operations. Moreover, FAA only maintains data on enforcement actions 
taken against air ambulance operators currently in operation. These 
data limitations constrain FAA's ability to assess its air ambulance 
oversight activities and are similar to the concerns we have previously 
reported about FAA's inadequate evaluative processes with its 
inspections and enforcement program.[Footnote 30] 

Part 135 Regulations Do Not Address Specific Dangers Inherent in Air 
Ambulance Transports: 

Many air ambulance flights are subject to different weather and crew- 
rest requirements under federal aviation regulations, depending on 
whether patients or passengers are on board. For example, flights 
without patients or passengers, such as flights en route to an accident 
scene or as part of training exercises, are subject to minimum 
requirements outlined in Part 91 regulations. When patients are on 
board, Part 135 requirements are applicable. Some operators we 
interviewed and visited reported that it is their company policy to 
follow Part 135 requirements at all times and believed that the more 
stringent requirements of Part 135 regulations offer safer operating 
parameters.[Footnote 31] 

Despite its more stringent requirements, Part 135 regulations cover a 
broad range of operators and do not address the risks inherent in the 
operational aspects of air ambulance transports--adding to FAA's 
challenges in providing oversight of the air ambulance industry. For 
example, Part 135 regulations do not distinguish the operational 
control responsibilities of the certificate holder from the base or 
hospital program, which may be important in this industry because many 
air ambulance operations are geographically dispersed or involve third 
parties, such as an emergency medical system communications specialist 
or medical director. In a recent review of Part 135 operators, FAA 
identified a problem of questionable operational control being 
exercised by certificate holders working under commercial arrangements 
with aircraft owners or management companies. In December 2006, FAA 
issued Notice 8000.347, which reiterates existing regulation about the 
exercise of operational control. The notice outlines that operational 
control requires Part 135 operators to "put procedures in place to 
ensure that when safety conditions for a flight cannot be met, the 
flight is canceled, delayed, rerouted, or diverted." Because multiple 
people are involved in dispatching air ambulance helicopters, 
operational control, as outlined within the current Part 135 
regulations, has been interpreted differently. According to one FAA 
official, in some instances, tracking a flight or "flight following"-- 
one function of operational control--was being performed by the 
hospital rather than the certificate holder because the former entities 
were in two-way communication with the helicopter. The official noted 
that this lack of formalized flight following inhibits the efficacy of 
the certificate holder in maintaining control of the aircraft and 
responsibility for the flight at all times. 

Part 135 regulations are also not tailored to the air ambulance 
industry's scene response transports that often require flights to 
remote sites. Remote-site flights may require crews to use new or 
different flight routes that can be further complicated by marginal 
weather or flying at night. Within Part 135 regulations, instrument 
flight rules allow for the use of instruments in guiding the aircraft 
in inclement weather. However, in order to utilize instrument flight 
rules equipment, weather reporting must be available for the 
destination location. According to Part 135 regulations, if such 
weather reporting is unavailable flights must use visual flight rules 
(not instrument). According to some operators, since many air ambulance 
flights are to remote landing sites or to hospitals that do not have 
such weather reporting available, air ambulances can be inhibited in 
their use of instrument flight rules equipment under Part 135. 
[Footnote 32] Some industry trade organizations consider flights that 
utilize instruments to be much safer than the flights that rely solely 
on visual cues. 

FAA Efforts to Improve Safety Are Under Way, but Effects Are Not Being 
Measured: 

While FAA has various efforts under way to address safety oversight of 
the air ambulance industry, the agency currently is not assessing the 
effects of these efforts. FAA's efforts have taken three main forms. 
First, FAA has issued numerous items of guidance for its inspectors and 
for air ambulance operators. The guidance directed at air ambulance 
operators is not subject to enforcement because it is not mandatory, 
and FAA has not established a way to track the extent to which 
operators are voluntarily implementing these practices. Second, FAA has 
authorized additional inspectors to oversee large air ambulance 
operators and taken other steps designed to improve the safety of large 
operations. Third, FAA has increased collaboration with air ambulance 
industry officials through sponsorship of and attendance at meetings 
and conferences that address industry safety issues. However, FAA has 
no way to measure the impacts of these safety efforts because FAA does 
not collect basic data about industry trends, such as flight hours, 
that are necessary to indicate if accident rates are increasing or 
decreasing. Additionally, the extent to which operators are following 
FAA voluntary guidance is not currently tracked. Without an approach 
for evaluating the effects of FAA efforts, it will be difficult to 
determine whether the current approach and level of FAA safety 
oversight of the air ambulance industry is appropriate. 

FAA Efforts Targeted at Improving Air Ambulance Safety Oversight 
Include Issuing Guidance, Expanding Inspection Resources, and 
Collaborating with the Industry: 

FAA has taken a number of steps to develop initiatives and strategies 
to reduce the number of air ambulance accidents. In August 2004, FAA 
established the FAA Emergency Medical Services Task Force to review and 
guide government and industry efforts to reduce air ambulance 
accidents. The FAA task force initiated a collaborative relationship 
with air ambulance industry officials that resulted in FAA developing 
and publishing numerous pieces of aviation safety guidance, including 
FAA notices aimed at improving the safety of air ambulances. 
Additionally, FAA has recently authorized an increase in the size of 
the inspection teams overseeing large air ambulance operators. Beyond 
the 2004 task force, FAA has worked together with the industry in a 
number of ways to help address the safety of air ambulances. 

FAA Guidance Focuses on Identified Safety Concerns: 

FAA has issued guidance for air ambulance inspectors and operators that 
focus on a number of safety issues identified by the FAA task force's 
review of air ambulance accidents (see table 3). FAA's recently 
published guidance has been largely targeted at FAA safety inspectors 
of air ambulance operators, but it also recommends actions for 
operators to take to improve safety. All published notices containing 
the guidance expire 1 year after their effective date. Key areas of 
emphasis for inspectors to relay to operators include improving 
decision-making skills, risk management, and operational control. 

Table 3: Key FAA Published Efforts to Improve Air Ambulance Safety: 

Date: January 2005; 
Type of action: Notice 8000.293 (on Jan. 28, 2006, became permanent 
through Safety Alert for Operators 06001); 
Title: Helicopter Emergency Medical Service Operations; 
Purpose: Provides guidance for FAA safety inspectors to help operators 
review pilot and mechanic decision-making skills, procedural adherence, 
and crew resource management practices. 

Date: August 2005; 
Type of action: Notice 8000.301; 
Title: Operational Risk Assessment Programs for Helicopter Emergency 
Medical Services; 
Purpose: Provides guidance to FAA inspectors to promote improved risk 
assessment programs and risk management tools and training to all 
flight crews, including medical staff. 

Date: September 2005; 
Type of action: Notice 8000.307; 
Title: Special Emphasis Inspection Program for Helicopter Emergency 
Medical Services; 
Purpose: Provides guidance to FAA safety inspectors of air ambulance 
operators to place emphasis on specific areas, including operational 
control (policies, procedures, training, etc), safety culture 
development, access to weather information, operators' knowledge of 
geographic area, etc. 

Date: September 2005; 
Type of action: Advisory Circular 00-64; 
Title: Air Medical Resource Management; 
Purpose: Provides guidance to operators to establish minimum training 
guidelines for all air medical team members. 

Date: January 2006; 
Type of action: Flight Standards Handbook Bulletin for Air 
Transportation, 06-02; 
Title: Helicopter Emergency Medical Services Loss of Control and 
Controlled Flight into Terrain Accident Avoidance Programs; 
Purpose: Provides information to inspectors about pilot training and 
checking standards and requires a review of air ambulance operator 
training programs. 

Date: January 2006; 
Type of action: Flight Standards Handbook Bulletin for Air 
Transportation, 06-01; 
Title: Helicopter Emergency Medical Services; OpSpec A021/A002 
Revisions; 
Purpose: Provides guidance to principal operations inspectors about 
revisions to the weather minimums for air ambulance operators. 

Date: March 2006; 
Type of action: Notice 8000.318; 
Title: Public Helicopter Emergency Medical Services Operations; 
Purpose: Provides guidance to inspectors to ensure that public air 
ambulance operators are aware of current FAA policies and standards for 
air ambulance operations, and to emphasize the importance of public 
aircraft operators' compliance with these operating rules. 

Date: August 2006; 
Type of action: Aeronautical Information Manual; 
Title: Helicopter Night Visual Flight Rule Operations; 
Purpose: Provides information and guidance concerning night celestial 
and man- made lighting on seeing conditions in night visual flight rule 
operations. 

Date: August 2006; 
Type of action: Aeronautical Information Manual; 
Title: Landing Zone Information; 
Purpose: Provides information and guidance on the selection of ad-hoc 
helicopter landing sites by ground responders and the use of such sites 
by helicopter operators. 

Date: November 2006; 
Type of action: Notice 8000.333; 
Title: Helicopter Emergency Medical Services (HEMS) use of the Aviation 
Digital Data Service (ADDS) Experimental HEMS Tool; Purpose: Provides 
information and guidance to principal inspectors on the use of the 
ceiling and visibility tool developed as a result of the 2006 Weather 
Summit. 

Source: FAA. 

[End of table] 

FAA notices require actions by FAA personnel but are nonmandatory to 
the air ambulance operators and not subject to enforcement. For 
example, in Notice 8000.301, which concerns risk assessment programs, 
principal inspectors are to review the notice, provide a copy to their 
assigned operators, and "strongly encourage" operators to implement a 
risk assessment program. FAA inspectors told us that this published 
guidance is difficult to enforce and agreed that although many of the 
air ambulance operators are proactive in implementing FAA guidance, 
there is no way to ensure that operators adopt the guidance. An 
official from Professional Airways Systems Specialists, the union 
representing FAA inspectors, also commented that principal inspectors 
have no way to compel operators to adopt this guidance, because the 
enforcement tools they have (e.g., approving the operators' general 
operating manuals and levying sanctions and fines) are rooted in 
established regulations, not in the "good ideas" of the voluntary 
guidance. Additionally, FAA officials noted that in areas where there 
has been some industry resistance, such as new equipment 
recommendations, inspectors have little recourse. However, FAA 
officials told us that rule making is a time-consuming process that can 
take years to complete, hindering the agency's ability to quickly 
respond to emerging issues. By issuing guidance rather than 
regulations, FAA has been able to quickly respond to concerns about air 
ambulance safety. Officials added that FAA has not ruled out future 
regulatory action. 

Industry officials and air ambulance operators we interviewed were 
largely supportive of FAA's efforts to provide additional guidance on 
air ambulance safety and reported that most operators are implementing 
this guidance. For example, CAMTS has adopted much of FAA's guidance 
within its accreditation standards for operators and, in cases such as 
risk assessment, has adopted more stringent standards than FAA 
encourages. Air ambulance operators also reported that they were 
already operating at higher standards than FAA recommends in guidance, 
such as weather minimums and safety equipment. Many industry groups and 
operators do not believe that additional regulations would be more 
effective than the published guidance. For example, the Helicopter 
Association International, a professional trade association for the 
civil helicopter industry, has stated that adherence to current 
regulations is far more effective than generating new regulations and 
has encouraged air ambulance operators to adopt FAA guidance to the 
maximum extent possible to enhance safety. 

Additional FAA Resources Allocated to Air Ambulance Oversight: 

FAA recently authorized the hiring of new inspectors to work on the 
certificate management teams for large air ambulance operators. In 
2005, FAA sanctioned a group to review the resource needs for oversight 
of air ambulance operators with 25 or more dedicated air ambulance 
helicopters. Following this review, the task team made several 
recommendations to FAA headquarters that included increasing the number 
of FAA inspectors assigned to large air ambulance operators, dedicating 
these inspectors solely to air ambulance operator certificates (i.e., 
no other inspection responsibilities), and using the surveillance and 
evaluation program (SEP) to identify risks and target surveillance 
activities.[Footnote 33] As a result of the task team recommendations, 
in June 2006, FAA accepted these recommendations and authorized an 
increase in the number of staff assigned to the inspection teams that 
oversee the seven large air ambulance operators.[Footnote 34] For four 
of the seven largest operators, the size of the inspection teams will 
increase to eight inspectors to oversee the air ambulance operator 
certificates.[Footnote 35] Additionally, the principal inspectors and 
newly hired inspectors for these operators will be dedicated to the 
certificate. Prior to this effort, many of the principal inspectors for 
large air ambulance operators were responsible for more than 20 
different certificates. Following this hiring, and implementation and 
use of SEP, FAA will evaluate whether a further increase in inspection 
team sizes is necessary. Hiring efforts by FAA to fill these inspector 
positions are under way, and hiring is expected to be completed in 
fiscal year 2007. 

FAA also initiated a series of efforts to improve the safety of one 
large air ambulance operator in 2005, and officials reported that they 
hope some of the changes and recommendations being adopted by this 
operator will be implemented industrywide. FAA concluded that the 
recent increase in accidents of this operator emphasized the need for a 
new approach to FAA's involvement in the effort to enhance safety for 
air ambulance operators in general. The team working with the operator 
has since recommended changes to FAA to improve oversight, including 
increased and more focused surveillance, relieving inspectors of other 
certificate duties, and adding appropriately qualified inspectors. 
Additionally, the team has worked closely with the operator to evaluate 
the company safety program, encourage risk management, and to change 
some parameters for flights, including weather minimums. 

FAA Has Increased Collaboration with the Industry: 

In addition to collaborating with the air ambulance industry on 
developing FAA guidance, FAA officials have worked together with the 
industry in a number of other ways, such as attending and participating 
in industry meetings, conferences, and task teams. For example, in 
March 2006, FAA hosted a Weather Summit to identify the air ambulance 
issues related to weather products and services and determine how FAA 
can better meet industry needs. Additionally, FAA officials participate 
in the AAMS Safety Committee and have made presentations at recent 
industry conferences, such as the Helicopter Safety Forum and the Air 
Medical Transport conference, to keep the industry informed of FAA 
efforts related to air ambulance oversight. 

FAA officials also reported that they are working with the industry to 
address recent NTSB safety concerns but have not issued any new 
regulations for air ambulance operators as NTSB recommended. In its 
January 2006 Special Investigation Report on air ambulance operations 
and accidents, NTSB made four recommendations to FAA to improve air 
ambulance safety (see table 4). With these recommendations NTSB 
encouraged FAA to impose requirements for air ambulance operators 
because NTSB does not anticipate that the recently published FAA 
guidance will be widely implemented by operators due to its voluntary 
nature.[Footnote 36] 

Table 4: NTSB Recommendations and FAA Responses: 

NTSB recommendation to FAA: Require all air ambulance operators to 
comply with Part 135 operations specifications during the conduct of 
all flights with medical personnel on board; 
FAA response: FAA is looking at options to address concerns about the 
differences in the flight rules--specifically the weather minimums--
through new weather reporting requirements and the application of 
"eligible on demand" standards to air ambulance helicopter operations. 

NTSB recommendation to FAA: Require all air ambulance operators to 
develop and implement flight risk evaluation programs; 
FAA response: FAA has implemented this recommendation with the 
publication of Notice 8000.301. 

NTSB recommendation to FAA: Require air ambulance operators to use 
formalized dispatch and flight-following procedures; 
FAA response: FAA has a study under way to identify best industry 
practices in ground communication and dispatch to support effective FAA 
requirements and policy. 

NTSB recommendation to FAA: Require air ambulance operators to install 
terrain awareness and warning systems on their aircraft and to provide 
adequate training to ensure that flight crews are capable of using the 
systems; 
FAA response: FAA has emphasized the strategic avoidance of controlled 
flight into terrain accidents in Flight Standards Handbook Bulletin for 
Air Transportation, 06-02. At FAA request, RTCA Inc., a private 
corporation, has formed a special committee to develop the minimum 
operational standards for helicopter terrain awareness and warning 
systems, which will be used by FAA in developing future requirements. 

Sources: NTSB and FAA. 

[End of table] 

Industry officials we spoke with generally agreed with the NTSB report 
recommendations but did raise some concerns. Some industry officials 
were concerned about the recommendation that air ambulances operate 
under Part 135 at all times, noting that this could inhibit transports 
in some areas due to a lack of weather information. For example, in a 
response letter addressed to NTSB, CAMTS stated that while the balance 
between lesser and more stringent regulation has always been a concern, 
it is difficult to operate under Part 135 regulations in rural areas 
due to airport and landing restrictions. Additionally, many industry 
officials expressed concerns about the costs related to implementing 
terrain awareness and warning systems, and some stated that this 
technology may not be appropriate for helicopters due to the low 
altitudes in which they operate. For example, AAMS has stated that the 
NTSB has seriously underestimated the costs involved in implementing 
terrain awareness and warning systems and has pointed out that, on one 
aircraft, the cost of the computer portion of this technology (which 
they say is the smallest part of the implementation costs) can range 
from $14,000 to $30,000. AAMS supports voluntary implementation of 
terrain awareness and warning systems due to the high costs involved in 
implementing the systems and limited proven benefits, especially in 
helicopter operations. 

FAA Lacks an Approach for Evaluating the Effects of Its Efforts: 

While the efforts by FAA could have had an effect on safety, the extent 
of any effect is unknown because FAA does not collect necessary data to 
evaluate effectiveness. FAA efforts such as increasing its inspector 
workforce allow FAA to conduct more inspections and potentially improve 
oversight of air ambulance operators. However, whether this increased 
attention results in a better safety record will be difficult to 
determine without the data to conduct an analysis of the industry 
accident rate. FAA does not currently collect basic data to measure 
changes in the air ambulance industry, such as flight hours or number 
of trips flown. Without data about the number of flights or flight 
hours, FAA and the air ambulance industry are unable to identify 
whether the increased number of accidents has resulted in an increased 
accident rate or whether it is a reflection of the growing number of 
aircraft and programs. Data describing the safety trends of the 
industry is essential to understanding the effects of FAA efforts, 
especially as FAA continues to develop initiatives and dedicate 
resources to improve air ambulance safety. NTSB has also stated the 
need for valid activity data for Part 135 operators, not only to 
compare accident rates, but also to establish baseline measures to be 
used to identify and track accident trends and to assess the 
effectiveness of safety improvement efforts.[Footnote 37] 

Air ambulance flight hours and number of trips, while not currently 
collected by FAA, appear readily available. According to current 
regulations, Part 135 operators are not required to maintain flight- 
hour activity data, but most FAA inspectors and air ambulance operators 
we spoke with said that this information is available. Air ambulance 
operators maintain records on the number of flights and flight hours 
for a number of reasons, including to track the maintenance of the 
helicopter equipment, to track the costs associated with flights (for 
billing purposes), and to make business decisions such as where to 
place additional aircraft or crew. Operators we spoke with did not 
express concerns about reporting flight-hour or trip information to 
FAA. FAA officials reported that principal inspectors can get this 
information from operators, but regulatory changes would be necessary 
to require operators to report it to FAA. To address the lack of 
national data, the industry has an effort under way to create a 
database of air ambulance flight operations information. This 
initiative is still in the preliminary stages. 

FAA also has no way to determine whether air ambulance operators are 
implementing published guidance. Although FAA inspectors are required 
to use FAA databases to record that guidance has been disseminated to 
air ambulance operators, there is no mechanism to report whether 
operators implemented the voluntary guidance. By issuing guidance for 
operators to adopt, rather than making changes through regulations, FAA 
has expedited the process of relaying safety information and 
encouraging safety initiatives by operators. However, without a 
mechanism to record whether operators are adopting this guidance, FAA 
is unable to link these efforts to any specific results. For example, 
according to Notice 8000.293, FAA inspectors were to encourage air 
ambulance operators to consider using enhanced vision systems and 
terrain awareness and warning systems for night operations. Without 
information about which operators adopted this guidance, FAA will not 
be able to link this effort to safer flights or fewer accidents and 
will thus be unable to determine whether voluntary guidance is an 
effective means to direct air ambulance operator safety efforts. 

Conclusions: 

The number of air ambulance accidents, while decreasing somewhat over 
the last 2 years, remains above historic levels. FAA and the industry 
have implemented numerous efforts to improve the safety of air 
ambulances. However, FAA lacks basic information on the industry and 
its safety efforts, including the number of flights and flight hours, 
the number and location of air ambulance aircraft, and the number of 
violations and enforcement actions against air ambulance operations. 
This inhibits FAA's ability to gain a complete understanding of the 
industry and whether its efforts are sufficient. FAA needs data about 
the air ambulance fleet and operations, as well as the ability to track 
and evaluate the implementation of its voluntary guidance to operators. 
Without this information, FAA cannot assess the safety of the industry. 
Further, this lack of information makes it difficult to determine the 
extent to which operators are making changes and the effect the efforts 
are having. Given the differences between air ambulance operators and 
other Part 135 operators FAA oversees, as well as the challenges FAA 
faces in responding to inherent safety concerns of the industry, a 
clear understanding of trends and actions taken appears important in 
deciding if the current regulatory approach is appropriate or if more 
fundamental changes, such as revising FAA regulations or inspection 
processes, need to be considered. 

Recommendations for Executive Action: 

To help FAA monitor industry growth trends, accident rates, and 
operator implementation of FAA guidance, we recommend that the 
Secretary of Transportation direct the Administrator of FAA to take the 
following two actions: 

* Identify the data necessary to better understand the air ambulance 
industry and develop a systematic approach for gathering and using this 
data. At a minimum, this data should include the number of flights and 
flight hours, the number and locations of air ambulance helicopters, 
and the number and types of FAA violations and enforcement actions 
related to the air ambulance fleet. 

* Collect information on the implementation of voluntary FAA guidance 
by air ambulance operators and evaluate the effectiveness of that 
guidance. 

Agency Comments and Our Evaluation: 

We provided a draft of this report to DOT for their review and comment. 
On February 8, 2007, we met with DOT and FAA officials, including the 
Deputy Director of FAA's Flight Standards Service, to obtain their oral 
comments on the draft report. Overall, these officials agreed with the 
report's findings and conclusions, and agreed to consider the 
recommendations. FAA officials also provided technical comments, which 
were incorporated in this report, as appropriate. We also provided a 
draft of this report to NTSB for their review and comment. On January 
30, 2007, NTSB's Audit Liaison provided technical comments, which were 
incorporated, as appropriate, and confirmed that NTSB agreed with the 
report's findings, conclusions, and recommendations via e-mail. In 
addition, we provided a draft of this report to AAMS since AAMS is a 
leading air ambulance industry representative. AAMS provided written 
comments, which are reprinted in appendix III. AAMS also provided 
technical comments, which were incorporated, as appropriate. 

As agreed with your office, unless you publicly announce the contents 
of this report earlier, we plan no further distribution until 14 days 
from the report date. At that time, we will send copies to appropriate 
congressional committees, the Secretary of Transportation, and the 
Chairman of the National Transportation Safety Board. We will also make 
copies available to others on request. In addition, the report is 
available at no charge on the GAO Web site at [Hyperlink, 
http://www.gao.gov]. 

If you have any questions about this report, please contact me at (202) 
512-2834 or dillinghamg@gao.gov. Contact points for our Offices of 
Congressional Relations and Public Affairs may be found on the last 
page of this report. GAO staff who made major contributions to this 
report are listed in appendix IV. 

Sincerely yours, 

Signed by: 

Gerald L. Dillingham, Ph.D. 
Director, Physical Infrastructure Issues: 

[End of section] 

Appendix I: Scope and Methodology: 

To identify and describe the recent trends in the air ambulance 
industry, we reviewed literature and analyzed data on industry 
composition, size, and accidents. The literature we reviewed included 
government, industry, and academic studies, reports, and other 
documents regarding the evolution of the industry in terms of 
composition, size, accidents, and safety initiatives. The Federal 
Aviation Administration (FAA) data included estimates of flight hours 
and aircraft based on its General Aviation and Air Taxi Activity and 
Avionics survey for 1999 to 2004, data on numbers of inspectors and 
operators (as of 2005), and numbers and types of violations and 
enforcement actions from various FAA databases for 1998 to 2005. The 
Association of Air Medical Services data, from the Atlas and Database 
of Air Medical Services, included numbers of bases and dedicated 
aircraft for 2003 to 2005. To examine the relationship between changes 
in Medicare reimbursement rules and industry trends, we analyzed data 
on Medicare reimbursed air ambulance trips from 1998 to 2005, as well 
as trips by type of air ambulance provider for 2001 and 2004; these 
data were obtained from the Medicare claims database. Based on reviews 
of data documentation, interviews with relevant officials, and tests 
for reasonableness, we determined that the data we used were 
sufficiently reliable for the purposes of our study. We also 
interviewed officials from the National Transportation Safety Board 
(NTSB), academic experts, and industry and trade group representatives 
about trends in the nature and scope of the industry and overall safety 
concerns. Table 5 lists the industry and trade organizations we 
contacted. 

Table 5: Industry and Trade Organizations Interviewed: 

Organizations: 
Air Medical Physicians Association. 
Air Medical Safety Advisory Council. 
Air, Surface, and Transport Nurses Association. 
Association of Air Medical Services. 
Commission on Accreditation of Medical Transport Systems. 
Helicopter Association International. 
International Association of Flight Paramedics. 
National Association of Air Communications Specialists. 
National Association of State Emergency Medical Services Officials. 
National Emergency Medical Services Pilots Association. 
Professional Airways Systems Specialists. 
R. Dixon Speas Associates. 

Source: GAO. 

[End of table] 

To assess challenges to FAA oversight, we reviewed federal laws, 
regulations, and guidance on air ambulance safety to better understand 
the nature and extent of FAA's oversight role. Further, we interviewed 
FAA Flight Standards officials in headquarters, inspectors, and 
certificate management teams for air ambulance operators, as well as 
industry officials and other experts, about air ambulance safety and 
challenges to FAA oversight. 

To help identify the key safety risks, we obtained and analyzed data 
from NTSB's Aviation Accident Database on accidents that occurred from 
January 1, 1998, to December 31, 2005. Our analysis of the NTSB data 
formed the basis of the descriptive and comparative information on air 
ambulance accidents shown throughout this report. According to NTSB, an 
aviation accident is "an occurrence associated with the operation of an 
aircraft which takes place between the time any person boards the 
aircraft with the intention of flight and all such persons have 
disembarked, and in which any person suffers death or serious injury, 
or in which the aircraft receives substantial damage." Accidents were 
included in our analysis as a helicopter air ambulance accident if the 
database showed (1) the accident involved a helicopter being operated 
by an air medical transport company and (2) the accident occurred 
during flight under either Part 91 or Part 135 regulations. For this 
period, we identified a total of 89 helicopter air ambulance accidents 
that occurred under Part 91 or Part 135 flight rules and analyzed data 
about these accidents to determine key contributing causes and 
factors.[Footnote 38] All accidents involving public operators were 
excluded from our analysis. We also conducted analyses comparing these 
89 air ambulance accidents with other helicopter accidents during the 
same time period. 

To assess the reliability of the NTSB data, we (1) performed electronic 
testing for accuracy, completeness, and consistency; (2) reviewed 
internal NTSB documents about its collection, entry, and maintenance; 
and (3) interviewed officials in NTSB's Office of Aviation Safety and 
Office of Research and Engineering who were knowledgeable about the 
content and limitations of these data. We determined that these data 
were sufficiently reliable for the nationwide descriptive and 
comparative analyses used in this report. We documented the procedures 
that we used in our analyses and submitted them to officials in NTSB's 
Office of Research and Engineering for their review and concurrence. 

To learn more about air ambulance safety risks and concerns, we 
conducted a total of five site visits of air ambulance providers in 
Arizona, California, Maryland, Texas, and Washington. We chose these 
states based on the presence of a large air ambulance market,[Footnote 
39] state accreditation requirements, or an operating public provider. 
To have access to a greater number of providers representing a variety 
of business models, operational characteristics, and accident 
histories, we narrowed our possible site visit locations to large air 
ambulance markets. To examine the relevance and describe the extent of 
state accreditation requirements, we included states with and without 
these requirements. Lastly, to learn about the policies and practices 
public providers may be engaged in that impact safety, we chose states 
that had a public operator. 

We selected the providers based on a number of operational 
characteristics to include a variety of business models (hospital-based 
and stand-alone programs, and public and private programs) and 
certificate holder arrangements (operating certificate held by program 
or vendor). During these site visits, we interviewed company officials, 
including pilots, and obtained documentation of some programs' flight 
safety protocols. Table 6 provides a description of each state we 
visited. 

Table 6: Description of States Selected for Site Visits: 

State: Arizona; 
Description of air ambulance market: 
Providers: 10; 
Helicopters: 50; 
Accidents, 1998 to 2005: 8; 
State requirements: The state requires licensing for all air ambulance 
providers through the Arizona Department of Health Services. Inspection 
and registration for all air ambulance units operating in Arizona is 
required on a yearly basis. If a provider is accredited by the 
Commission on Accreditation of Medical Transport Systems (CAMTS), the 
state requirement for a licensure inspection is waived; 
Description of programs visited: 
* Native Air, a subsidiary of Omniflight Helicopters, is a community- 
based operator, and its fleet is composed of 15 helicopters located at 
12 bases in Arizona and Montana. 

State: California; 
Description of air ambulance market: 
Providers: 28; 
Helicopters: 72; 
Accidents, 1998 to 2005: 7; 
State requirements: The state of California has delegated authority to 
local governments for emergency medical services (EMS). County 
governments are responsible for coordinating emergency medical 
services, including the coordination and monitoring of air ambulance 
services; 
Description of programs visited: 
* The FlightCare Program at Enloe Medical Center is a nonprofit 
hospital-based program. The program's fleet consists of one helicopter 
based at the Enloe Hospital helipad; 
* REACH is an independent for-profit air ambulance provider. The 
company has seven helicopters and nine bases in California and Oregon; 
* CALSTAR is a nonprofit community-based program. The company's fleet 
consists of 11 helicopters and seven bases in California; 
* The California Highway Patrol operates as an air rescue provider. The 
California Highway Patrol maintains a fleet of 14 helicopters, 11 of 
which are partially used for medical emergency transport and air 
rescue. These helicopters are based at nine locations throughout the 
state. 

State: Maryland; 
Description of air ambulance market: 
Providers: 3; 
Helicopters: 18; 
Accidents, 1998 to 2005: 1; 
State requirements: Maryland requires private providers of air 
ambulance services operating in the state to be licensed by the state 
and CAMTS accredited; 
Description of programs visited: 
* The Maryland State Police Aviation Command is a public provider and 
has a fleet of 12 helicopters based in eight locations across the 
state. 

State: Texas; 
Description of air ambulance market: 
Providers: 23; 
Helicopters: 61; 
Accidents, 1998 to 2005: 13; 
State requirements: The state requires air ambulances and providers to 
be licensed by the Texas Department of State Health Services. The 
licensure process requires providers to submit a copy of their current 
FAA operational certification that includes designation for air 
ambulance operations; 
Description of programs visited: 
* Teddy Bear Transport of Cook Children's Medical Center is a hospital-
based program that conducts hospital-to-hospital transports for 
pediatric patients. The program contracts with a vendor for its 
aviation services and operates one helicopter; 
* PHI Air Medical is an independent program conducting a mix of scene 
response and hospital-to-hospital transports. PHI's programs in Texas 
include 12 helicopters stationed at 12 bases. In total, the company has 
224 air ambulance helicopters stationed at 49 bases in 14 states. 

State: Washington; 
Description of air ambulance market: 
Providers: 2; 
Helicopters: 10; 
Accidents, 1998 to 2005: 3; 
State requirements: The state requires providers and air ambulances to 
be licensed through the Washington Department of Health. Providers must 
be accredited by CAMTS. Air ambulance licensure applicants must affirm 
in the application that their service meets all FAA regulations, and 
they must also provide a copy of their current FAA certificate and 
operational specifications; 
Description of programs visited: 
* Airlift Northwest is a nonprofit community-based program. The program 
contracts out its aviation services. Its fleet consists of six 
helicopters stationed at four bases in Washington. 

Source: GAO. 

[End of table] 

To supplement information gathered through interviews and visits with 
local program officials, we also conducted semistructured interviews 
with management officials from five of the largest air ambulance 
operators to discuss air ambulance safety and trends. We also met with 
local geographic and assigned principal FAA inspectors to learn more 
about their roles and responsibilities in the oversight of the programs 
we visited. 

To describe the FAA efforts in addressing safety oversight challenges, 
we identified and reviewed regulatory and voluntary guidance 
implemented by FAA to address safety in the air ambulance industry. We 
reviewed advisory circulars, notices, and other guidance issued by FAA 
since 2004. We also obtained and reviewed documentation of FAA's 
heightened oversight of one air ambulance operator and other documents 
regarding staffing levels for the certificate management teams of large 
air ambulance operators. 

[End of section] 

Appendix II: NTSB Air Ambulance Accident Data: 

According to NTSB, from January 1998 through 2005, 89 air ambulance 
accidents took place, resulting in 75 fatalities, 31 serious injuries, 
and 27 minor injuries. An additional 133 people involved in these 
accidents suffered no injuries. Of the 89 accidents, 64 took place 
during Part 91 flight and the remaining 25 took place during Part 135 
flight. Forty-seven of the accidents took place during the night and 
the remaining 42 took place during the day. Table 7 provides 
information collected from NTSB on each of these accidents. 

Table 7: NTSB Air Ambulance Accident Information, 1998 through 2005: 

Year: 1998; 
Flight regulation: 135; 
When accident occurred: Night; 
Number of fatalities, injuries, or uninjured: 4 fatalities; 
State: UT; 
Accident details: An air ambulance helicopter transporting an injured 
skier to a hospital was destroyed when it collided with mountainous 
terrain after flying into known adverse weather. 

Year: 1998; 
Flight regulation: 91; 
When accident occurred: Day; 
Number of fatalities, injuries, or uninjured: 3 injuries; 
State: AR; 
Accident details: An air ambulance helicopter en route to pick up a 
patient from a hospital was substantially damaged during a hard landing 
following a loss of engine power. 

Year: 1998; 
Flight regulation: 91; 
When accident occurred: Night; 
Number of fatalities, injuries, or uninjured: 3 fatalities; 
State: TX; 
Accident details: An air ambulance helicopter en route to an accident 
scene collided with terrain and trees after encountering poor 
visibility conditions. 

Year: 1998; 
Flight regulation: 91; 
When accident occurred: Night; 
Number of fatalities, injuries, or uninjured: 3 uninjured; 
State: CA; 
Accident details: An air ambulance helicopter was destroyed when it 
rolled over while attempting to land at a makeshift landing zone near 
an accident site. 

Year: 1998; 
Flight regulation: 91; 
When accident occurred: Night; 
Number of fatalities, injuries, or uninjured: 3 fatalities; 
State: IA; 
Accident details: Due to faulty components, an air ambulance helicopter 
experienced an in-flight breakup during descent and was destroyed. 

Year: 1998; 
Flight regulation: 135; 
When accident occurred: Night; 
Number of fatalities, injuries, or uninjured: 4 uninjured; 
State: ID; 
Accident details: An air ambulance helicopter taking off from an off-
site landing zone sustained substantial damage when it collided with 
wires. 

Year: 1999; 
Flight regulation: 91; 
When accident occurred: Night; 
Number of fatalities, injuries, or uninjured: 3 injuries; 
State: OH; 
Accident details: An air ambulance helicopter en route to pick up a 
patient from a hospital was destroyed when it impacted a house after 
the pilot inadvertently entered snowy conditions. 

Year: 1999; 
Flight regulation: 135; 
When accident occurred: Day; 
Number of fatalities, injuries, or uninjured: 5 uninjured; 
State: TX; 
Accident details: An air ambulance helicopter transporting a patient to 
a hospital from an accident scene was substantially damaged when it 
impacted power lines during takeoff. 

Year: 1999; 
Flight regulation: 91; 
When accident occurred: Night; 
Number of fatalities, injuries, or uninjured: 3 fatalities; 
State: NV; 
Accident details: An air ambulance helicopter returning to base after 
transporting a patient to a hospital was destroyed after encountering 
deteriorating weather conditions and colliding with terrain. 

Year: 1999; 
Flight regulation: 91; 
When accident occurred: Day; 
Number of fatalities, injuries, or uninjured: 3 uninjured; 
State: FL; 
Accident details: An air ambulance helicopter en route to pick up a 
patient collided with a building while hovering in preparation for 
takeoff. 

Year: 1999; 
Flight regulation: 91; 
When accident occurred: Day; 
Number of fatalities, injuries, or uninjured: 1 uninjured; 
State: MO; 
Accident details: An air ambulance helicopter impacted terrain (during 
takeoff from a helipad located on top of a hospital) because an 
auxiliary power line was still attached to the helicopter. 

Year: 1999; 
Flight regulation: 91; 
When accident occurred: Night; 
Number of fatalities, injuries, or uninjured: 3 injuries; 
State: FL; 
Accident details: An air ambulance helicopter crashed when approaching 
an off-site landing zone to pick up a patient. 

Year: 1999; 
Flight regulation: 135; 
When accident occurred: Day; 
Number of fatalities, injuries, or uninjured: 4 uninjured; 
State: MT; 
Accident details: An air ambulance helicopter collided with a tower 
during takeoff from a remote site. 

Year: 2000; 
Flight regulation: 91; 
When accident occurred: Night; 
Number of fatalities, injuries, or uninjured: 3 uninjured; 
State: TN; 
Accident details: An air ambulance helicopter was substantially damaged 
when it collided with a tree while attempting to land at a roadside 
landing zone. 

Year: 2000; 
Flight regulation: 135; 
When accident occurred: Night; 
Number of fatalities, injuries, or uninjured: 4 fatalities; 
State: TX; 
Accident details: An air ambulance helicopter transporting a patient to 
a hospital was destroyed when it impacted terrain after flying into 
known adverse weather conditions. 

Year: 2000; 
Flight regulation: 91; 
When accident occurred: Day; 
Number of fatalities, injuries, or uninjured: 2 uninjured; 
State: MN; 
Accident details: An air ambulance helicopter returning from dropping 
off a patient was substantially damaged from an in-flight collision 
with a warehouse. 

Year: 2000; 
Flight regulation: 91; 
When accident occurred: Day; 
Number of fatalities, injuries, or uninjured: 3 fatalities; 
State: FL; 
Accident details: An air ambulance helicopter traveling back to base 
after completing an interfacility transport collided with a radio 
transmission tower and was destroyed. 

Year: 2000; 
Flight regulation: 91; 
When accident occurred: Night; 
Number of fatalities, injuries, or uninjured: 3 uninjured; 
State: TX; 
Accident details: An air ambulance helicopter was substantially damaged 
when the tail rotor contacted trees while attempting to land at an 
accident site. 

Year: 2000; 
Flight regulation: 91; 
When accident occurred: Night; 
Number of fatalities, injuries, or uninjured: 3 fatalities; 
State: GA; 
Accident details: An air ambulance helicopter returning to base was 
destroyed when it collided with trees and the ground during flight. 

Year: 2000; 
Flight regulation: 91; 
When accident occurred: Day; 
Number of fatalities, injuries, or uninjured: 1 uninjured; 
State: MN; 
Accident details: An air ambulance helicopter departing for refueling 
was substantially damaged during takeoff from a hospital helipad during 
windy conditions. 

Year: 2000; 
Flight regulation: 135; 
When accident occurred: Day; 
Number of fatalities, injuries, or uninjured: 4 injuries; 
State: AZ; 
Accident details: An air ambulance helicopter attempting to airlift a 
seriously injured patient impacted trees and terrain and was 
substantially damaged. 

Year: 2000; 
Flight regulation: 91; 
When accident occurred: Night; 
Number of fatalities, injuries, or uninjured: 1 fatality; 
State: NC; 
Accident details: An air ambulance helicopter experiencing mechanical 
difficulties collided with terrain and was destroyed. The accident 
occurred after a mechanic had taken insufficient action to fix the 
problem. 

Year: 2000; 
Flight regulation: 91; 
When accident occurred: Night; 
Number of fatalities, injuries, or uninjured: 3 uninjured; 
State: NV; 
Accident details: An air ambulance helicopter attempting to pick up a 
patient at a remote site collided with the ground during an aborted 
landing and sustained substantial damage. 

Year: 2000; 
Flight regulation: 91; 
When accident occurred: Night; 
Number of fatalities, injuries, or uninjured: 3 injuries; 
State: AZ; 
Accident details: An air ambulance helicopter on a positioning flight 
sustained substantial damage when the pilot became ill and lost control 
just before landing. 

Year: 2001; 
Flight regulation: 91; 
When accident occurred: Night; 
Number of fatalities, injuries, or uninjured: 1 injury,; 
2 uninjured; 
State: IL; 
Accident details: An air ambulance helicopter readying for takeoff 
received minor damage when a hospital security guard walked into the 
tail rotor. 

Year: 2001; 
Flight regulation: 91; 
When accident occurred: Day; 
Number of fatalities, injuries, or uninjured: 1 fatality; 
State: CO; 
Accident details: An air ambulance helicopter conducting a 
postmaintenance flight check was destroyed when it impacted the ground 
after losing rotor speed. 

Year: 2001; 
Flight regulation: 91; 
When accident occurred: Day; 
Number of fatalities, injuries, or uninjured: 2 injuries; 
State: NY; 
Accident details: An air ambulance helicopter on a positioning flight 
was substantially damaged during a precautionary landing following a 
mechanical malfunction. 

Year: 2001; 
Flight regulation: 91; 
When accident occurred: Day; 
Number of fatalities, injuries, or uninjured: 3 uninjured; 
State: WY; 
Accident details: An air ambulance helicopter conducting an off- site 
landing was substantially damaged when its tail rotor impacted a 
barrel. 

Year: 2001; 
Flight regulation: 91; 
When accident occurred: Day; 
Number of fatalities, injuries, or uninjured: 3 uninjured; 
State: AZ; 
Accident details: An air ambulance helicopter on a positioning flight 
was substantially damaged during a forced landing following a reported 
loss of engine power. 

Year: 2001; 
Flight regulation: 135; 
When accident occurred: Day; 
Number of fatalities, injuries, or uninjured: 4 uninjured; 
State: OR; 
Accident details: An air ambulance helicopter departing an off-site 
landing zone had to conduct an emergency landing because of a fire in 
the aircraft. 

Year: 2001; 
Flight regulation: 91; 
When accident occurred: Day; 
Number of fatalities, injuries, or uninjured: 3 injuries; 
State: TX; 
Accident details: An air ambulance helicopter en route to pick up a 
patient was substantially damaged when it impacted trees and terrain 
following a loss of engine power. 

Year: 2001; 
Flight regulation: 135; 
When accident occurred: Day; 
Number of fatalities, injuries, or uninjured: 4 uninjured; 
State: CA; 
Accident details: An air ambulance helicopter encountering low 
visibility conditions rolled onto its side during takeoff from a remote 
location. 

Year: 2001; 
Flight regulation: 91; 
When accident occurred: Night; 
Number of fatalities, injuries, or uninjured: 1 fatality,; 
1 injury,; 
1 uninjured; 
State: CA; 
Accident details: An air ambulance helicopter attempting to land at an 
off-site landing zone was destroyed when it encountered brownout 
conditions and collided with trees. 

Year: 2001; 
Flight regulation: 91; 
When accident occurred: Night; 
Number of fatalities, injuries, or uninjured: 2 injuries,; 
1 uninjured; 
State: TX; 
Accident details: An air ambulance helicopter on a nighttime 
positioning flight was substantially damaged during a hard landing 
following a total loss of engine power. 

Year: 2001; 
Flight regulation: 91; 
When accident occurred: Night; 
Number of fatalities, injuries, or uninjured: 1 injury; 
State: ID; 
Accident details: An air ambulance helicopter on a nighttime 
repositioning flight was destroyed when it collided with terrain after 
the pilot became spatially disoriented. 

Year: 2002; 
Flight regulation: 91; 
When accident occurred: Night; 
Number of fatalities, injuries, or uninjured: 2 fatalities,; 
1 injury; 
State: OH; 
Accident details: An air ambulance helicopter was destroyed when it 
collided with a brick façade during a takeoff from a rooftop helipad in 
windy conditions. 

Year: 2002; 
Flight regulation: 91; 
When accident occurred: Day; 
Number of fatalities, injuries, or uninjured: 1 fatality,; 
2 injuries; 
State: CA; 
Accident details: An air ambulance helicopter en route to pick up a 
patient was substantially damaged when the pilot became visually 
disoriented and collided with the surface of a lake. 

Year: 2002; 
Flight regulation: 91; 
When accident occurred: Night; 
Number of fatalities, injuries, or uninjured: 3 uninjured; 
State: AR; 
Accident details: An air ambulance helicopter was substantially damaged 
when its tail rotor struck trees during an approach to a landing zone. 

Year: 2002; 
Flight regulation: 91; 
When accident occurred: Day; 
Number of fatalities, injuries, or uninjured: 3 uninjured; 
State: FL; 
Accident details: An air ambulance helicopter experiencing mechanical 
trouble was substantially damaged when it performed a forced landing. 

Year: 2002; 
Flight regulation: 91; 
When accident occurred: Day; 
Number of fatalities, injuries, or uninjured: 3 fatalities; 
State: NE; 
Accident details: An air ambulance helicopter en route to pick up a 
patient was destroyed when it experienced a loss of control and a 
corresponding collision with terrain. 

Year: 2002; 
Flight regulation: 135; 
When accident occurred: Night; 
Number of fatalities, injuries, or uninjured: 5 uninjured; 
State: FL; 
Accident details: An air ambulance helicopter transporting a patient 
had an engine fire and was forced to conduct an emergency landing. 

Year: 2002; 
Flight regulation: 91; 
When accident occurred: Day; 
Number of fatalities, injuries, or uninjured: 4 injuries; 
State: FL; 
Accident details: An air ambulance helicopter en route to pick up a 
patient collided with a corner of a multistory parking garage during 
takeoff from a hospital helipad. 

Year: 2002; 
Flight regulation: 91; 
When accident occurred: Night; 
Number of fatalities, injuries, or uninjured: 3 fatalities; 
State: CA; 
Accident details: An air ambulance helicopter en route to an accident 
scene was destroyed after impacting terrain while maneuvering. 

Year: 2002; 
Flight regulation: 135; 
When accident occurred: Night; 
Number of fatalities, injuries, or uninjured: 4 fatalities; 
State: SD; 
Accident details: An air ambulance helicopter completing a nighttime 
interfacility transport crashed into terrain and was destroyed after 
the pilot lost control. 

Year: 2002; 
Flight regulation: 91; 
When accident occurred: Day; 
Number of fatalities, injuries, or uninjured: 3 uninjured; 
State: TX; 
Accident details: An air ambulance helicopter sustained substantial 
damage following a loss of control while attempting to take off from a 
hospital helipad. 

Year: 2002; 
Flight regulation: 91; 
When accident occurred: Day; 
Number of fatalities, injuries, or uninjured: 1 uninjured; 
State: KY; 
Accident details: An air ambulance helicopter experiencing a loss of 
control was substantially damaged during an emergency landing at an off-
site landing zone. 

Year: 2002; 
Flight regulation: 135; 
When accident occurred: Day; 
Number of fatalities, injuries, or uninjured: 4 uninjured; 
State: WA; 
Accident details: An air ambulance helicopter, while conducting an 
interfacility transport, sustained substantial damage when it 
encountered whiteout snow conditions and completed a hard emergency 
landing. 

Year: 2002; 
Flight regulation: 91; 
When accident occurred: Night; 
Number of fatalities, injuries, or uninjured: 3 uninjured; 
State: NY; 
Accident details: An air ambulance helicopter was substantially damaged 
after encountering a gust of wind during an engine startup on a rooftop 
helipad. 

Year: 2003; 
Flight regulation: 91; 
When accident occurred: Night; 
Number of fatalities, injuries, or uninjured: 2 fatalities,; 
1 injury; 
State: UT; 
Accident details: An air ambulance helicopter crashed into terrain 
after encountering dense fog while on an aborted mission to pick up a 
patient. 

Year: 2003; 
Flight regulation: 91; 
When accident occurred: Night; 
Number of fatalities, injuries, or uninjured: 1 fatality; 
State: IL; 
Accident details: An air ambulance helicopter operating in reduced 
visibility conditions was destroyed as a result of a collision with 
terrain. 

Year: 2003; 
Flight regulation: 91; 
When accident occurred: Day; 
Number of fatalities, injuries, or uninjured: 1 injury,; 
2 uninjured; 
State: TX; 
Accident details: An air ambulance helicopter en route to pick up a 
patient for interfacility transport sustained substantial damage when 
it impacted terrain during a hard landing. 

Year: 2003; 
Flight regulation: 91; 
When accident occurred: Day; 
Number of fatalities, injuries, or uninjured: 3 uninjured; 
State: TX; 
Accident details: An air ambulance helicopter was substantially damaged 
after a tail rotor drive failed during flight as a result of a blanket 
coming into contact with the tail rotor blades due to an unsecured 
cargo door. 

Year: 2003; 
Flight regulation: 135; 
When accident occurred: Night; 
Number of fatalities, injuries, or uninjured: 1 uninjured; 
State: MI; 
Accident details: An air ambulance helicopter at an off-site landing 
zone was substantially damaged when the tail rotor impacted a roadway 
sign during an aerial taxi. 

Year: 2003; 
Flight regulation: 91; 
When accident occurred: Day; 
Number of fatalities, injuries, or uninjured: 3 uninjured; 
State: PA; 
Accident details: An air ambulance helicopter conducted an emergency 
landing because a flashlight left on the tail boom came into contact 
with the tail rotor blades. 

Year: 2003; 
Flight regulation: 91; 
When accident occurred: Day; 
Number of fatalities, injuries, or uninjured: 1 fatality,; 
1 injury,; 
1 uninjured; 
State: UT; 
Accident details: An air ambulance helicopter en route to its home base 
after completing a patient transport was destroyed when it impacted a 
hillside. 

Year: 2003; 
Flight regulation: 135; 
When accident occurred: Day; 
Number of fatalities, injuries, or uninjured: 3 injuries,; 
1 uninjured; 
State: FL; 
Accident details: An air ambulance helicopter crashed while attempting 
to take off from an off-site landing zone. 

Year: 2003; 
Flight regulation: 91; 
When accident occurred: Day; 
Number of fatalities, injuries, or uninjured: 3 injuries; 
State: NY; 
Accident details: An air ambulance helicopter was substantially damaged 
during a forced landing when the pilot misinterpreted power loss. 

Year: 2003; 
Flight regulation: 135; 
When accident occurred: Day; 
Number of fatalities, injuries, or uninjured: 4 uninjured; 
State: CA; 
Accident details: An air ambulance helicopter in the process of 
transporting a patient made an emergency off-airport landing after 
experiencing severe in-flight vibrations. 

Year: 2003; 
Flight regulation: 91; 
When accident occurred: Night; 
Number of fatalities, injuries, or uninjured: 3 uninjured; 
State: IL; 
Accident details: An air ambulance helicopter executed a precautionary 
landing to a vacant parking lot after the helicopter encountered an in-
flight vibration. 

Year: 2003; 
Flight regulation: 91; 
When accident occurred: Night; 
Number of fatalities, injuries, or uninjured: 1 injury,; 
2 uninjured; 
State: TX; 
Accident details: An air ambulance helicopter sustained substantial 
damage when it impacted a safety fence and rolled over during an 
aborted takeoff following a partial loss of engine power. 

Year: 2003; 
Flight regulation: 135; 
When accident occurred: Night; 
Number of fatalities, injuries, or uninjured: 3 uninjured; 
State: IN; 
Accident details: An air ambulance helicopter sustained substantial 
damage during a hard landing in a gravel lot after losing visibility 
due to dust. 

Year: 2003; 
Flight regulation: 135; 
When accident occurred: Day; 
Number of fatalities, injuries, or uninjured: 4 uninjured; 
State: AZ; 
Accident details: An air ambulance helicopter transporting a patient 
experienced a loss of control due to mechanical failure and crashed on 
a taxiway during an emergency landing. 

Year: 2003; 
Flight regulation: 91; 
When accident occurred: Day; 
Number of fatalities, injuries, or uninjured: 1 injury; 
State: AR; 
Accident details: An air ambulance helicopter was substantially damaged 
following a loss of control during engine start because the main rotor 
was still tied down. 

Year: 2003; 
Flight regulation: 91; 
When accident occurred: Night; 
Number of fatalities, injuries, or uninjured: 3 uninjured; 
State: TX; 
Accident details: An air ambulance helicopter readying for an off-site 
landing sustained substantial damage when the tail rotor blades 
impacted trees while maneuvering. 

Year: 2003; 
Flight regulation: 91; 
When accident occurred: Night; 
Number of fatalities, injuries, or uninjured: 3 uninjured; 
State: KY; 
Accident details: An air ambulance helicopter landing at an off-site 
landing zone was substantially damaged when its tail rotor struck a 
hydrant that had not been identified by ground personnel. 

Year: 2003; 
Flight regulation: 91; 
When accident occurred: Night; 
Number of fatalities, injuries, or uninjured: 3 fatalities; 
State: CA; 
Accident details: An air ambulance helicopter on the way to pick up a 
patient crashed into mountainous terrain during high winds and heavy 
rain. 

Year: 2004; 
Flight regulation: 135; 
When accident occurred: Night; 
Number of fatalities, injuries, or uninjured: 4 fatalities,; 
1 injury; 
State: TX; 
Accident details: An air ambulance helicopter transporting a patient 
crashed into terrain while maneuvering in reduced visibility. 

Year: 2004; 
Flight regulation: 135; 
When accident occurred: Night; 
Number of fatalities, injuries, or uninjured: 1 fatality,; 
3 injuries; 
State: IN; 
Accident details: An air ambulance helicopter transporting a patient 
was substantially damaged when it collided with terrain. 

Year: 2004; 
Flight regulation: 91; 
When accident occurred: Day; 
Number of fatalities, injuries, or uninjured: 3 uninjured; 
State: TX; 
Accident details: An air ambulance helicopter sustained substantial 
damage when its tail rotor struck a parked helicopter while hovering 
prior to takeoff from a helipad. 

Year: 2004; 
Flight regulation: 91; 
When accident occurred: Day; 
Number of fatalities, injuries, or uninjured: 3 uninjured; 
State: AZ; 
Accident details: An air ambulance helicopter landing at an off- site 
landing zone was substantially damaged after a hard landing in low 
visibility conditions. 

Year: 2004; 
Flight regulation: 135; 
When accident occurred: Night; 
Number of fatalities, injuries, or uninjured: 4 fatalities; 
State: SC; 
Accident details: An air ambulance helicopter flying in mist and light 
fog collided with trees shortly after picking up a patient at an 
Interstate accident site. 

Year: 2004; 
Flight regulation: 135; 
When accident occurred: Day; 
Number of fatalities, injuries, or uninjured: 4 uninjured; 
State: ID; 
Accident details: An air ambulance helicopter was substantially damaged 
while maneuvering at an accident site during windy conditions. 

Year: 2004; 
Flight regulation: 135; 
When accident occurred: Night; 
Number of fatalities, injuries, or uninjured: 5 fatalities; 
State: NV; 
Accident details: An air ambulance helicopter crashed into mountainous 
terrain at night and in deteriorating weather conditions. 

Year: 2004; 
Flight regulation: 91; 
When accident occurred: Night; 
Number of fatalities, injuries, or uninjured: 1 injury; 
State: NM; 
Accident details: An air ambulance helicopter on a positioning flight 
was substantially damaged after liftoff when the helicopter's skid 
struck the helipad and caused the helicopter to roll over. 

Year: 2004; 
Flight regulation: 91; 
When accident occurred: Night; 
Number of fatalities, injuries, or uninjured: 3 fatalities; 
State: FL; 
Accident details: An air ambulance helicopter attempting to return to 
base after abandoning a mission due to bad weather was destroyed when 
it crashed into water. 

Year: 2004; 
Flight regulation: 91; 
When accident occurred: Day; 
Number of fatalities, injuries, or uninjured: 3 uninjured; 
State: AZ; 
Accident details: An air ambulance helicopter flying to pick up a 
patient experienced a partial power loss, followed by a hard landing in 
a parking lot. 

Year: 2004; 
Flight regulation: 135; 
When accident occurred: Night; 
Number of fatalities, injuries, or uninjured: 2 injuries,; 
1 uninjured; 
State: OK; 
Accident details: An air ambulance helicopter was substantially damaged 
when it impacted terrain following a loss of control due to a blanket 
coming in contact with the tail rotor blades during flight. 

Year: 2004; 
Flight regulation: 91; 
When accident occurred: Night; 
Number of fatalities, injuries, or uninjured: 1 fatality,; 
2 injuries; 
State: AZ; 
Accident details: An air ambulance helicopter was destroyed when it 
collided with terrain while attempting to land at an off-site landing 
zone. 

Year: 2005; 
Flight regulation: 91; 
When accident occurred: Day; 
Number of fatalities, injuries, or uninjured: 1 injury,; 
1 uninjured; 
State: AZ; 
Accident details: An air ambulance helicopter readying to land at an 
airport experienced loss of control and collided with terrain. 

Year: 2005; 
Flight regulation: 91; 
When accident occurred: Night; 
Number of fatalities, injuries, or uninjured: 1 fatality; 
State: MS; 
Accident details: An air ambulance helicopter was destroyed after 
colliding with trees and the ground in adverse weather conditions. 

Year: 2005; 
Flight regulation: 91; 
When accident occurred: Night; 
Number of fatalities, injuries, or uninjured: 2 fatalities,; 
1 injury; 
State: MD; 
Accident details: An air ambulance helicopter returning to base was 
destroyed after impacting water. 

Year: 2005; 
Flight regulation: 135; 
When accident occurred: Day; 
Number of fatalities, injuries, or uninjured: 1 fatality,; 
3 injuries; 
State: AR; 
Accident details: An air ambulance helicopter transporting a patient 
lost control and was substantially damaged during a hard landing. 

Year: 2005; 
Flight regulation: 91; 
When accident occurred: Day; 
Number of fatalities, injuries, or uninjured: 3 fatalities; 
State: CO; 
Accident details: An air ambulance helicopter was substantially damaged 
when it impacted terrain while approaching an off-site landing zone. 

Year: 2005; 
Flight regulation: 135; 
When accident occurred: Day; 
Number of fatalities, injuries, or uninjured: 4 uninjured; 
State: IN; 
Accident details: An air ambulance helicopter was substantially damaged 
following an in-flight loss of control after it impacted the helipad 
after takeoff. 

Year: 2005; 
Flight regulation: 91; 
When accident occurred: Day; 
Number of fatalities, injuries, or uninjured: 3 uninjured; 
State: FL; 
Accident details: An air ambulance helicopter sustained substantial 
damage when it rolled over while conducting an emergency landing after 
takeoff. 

Year: 2005; 
Flight regulation: 91; 
When accident occurred: Night; 
Number of fatalities, injuries, or uninjured: 3 fatalities; 
State: WA; 
Accident details: An air ambulance helicopter was destroyed when it 
impacted ocean waters while returning to base. 

Year: 2005; 
Flight regulation: 91; 
When accident occurred: Night; 
Number of fatalities, injuries, or uninjured: 1 fatality; 
State: PA; 
Accident details: An air ambulance helicopter on a refueling flight was 
destroyed when it impacted trees and terrain while performing an 
instrument approach to the airport. 

Year: 2005; 
Flight regulation: 135; 
When accident occurred: Night; 
Number of fatalities, injuries, or uninjured: 1 injury,; 
3 uninjured; 
State: WA; 
Accident details: An air ambulance helicopter during takeoff sustained 
substantial damage after impacting an object and subsequently impacting 
terrain. 

Year: 2005; 
Flight regulation: 91; 
When accident occurred: Day; 
Number of fatalities, injuries, or uninjured: 3 uninjured; 
State: MN; 
Accident details: An air ambulance helicopter sustained substantial 
damage during an aborted takeoff after a loss of power. 

Source: GAO analysis of NTSB data. 

[End of table] 

[End of section] 

Appendix III Comments from the Association of Air Medical Services: 

Association of Air Medical Services: 
526 King Street: 
Suite 415: 
Alexandria, VA 22314-3143: 
(703) 836-8732: 
FAX (703) 836-8920: 
www.aams.org: 

February 6, 2007: 

Dr. Gerald L. Dillingham: 
Director of Civil Aviation Issues: 
U.S. Government Accountability Office: 
441 G St. NW, Room 2T23B: 
Washington, DC 20548: 

RE: GAO Report on Air Medical Services: 

Dear Dr. Dillingham: 

The Association of Air Medical Services (AAMS) thanks the Government 
Accountability Office (GAO) for the opportunity to comment on this 
report, and we commend the members of the GAO research team for all of 
their efforts to continually engage the air medical community in the 
course of their research. The entire investigation process was 
conducted in an open and professional manner from the onset. We believe 
that this spirit of openness and cooperation led to an excellent 
report, despite the limited time the investigative team had to study 
and understand the complexities of the air medical community and its 
importance in providing timely patient care and transport. 

Overall, AAMS supports the recommendations made in the GAO Report on 
Air Medical Services. It is our belief that increased data collection 
in the air medical community, and in the aviation community as a whole, 
will lead to better research and a much more focused understanding of 
the importance of air medical services and the need for a more robust 
infrastructure to support this vital service. While AAMS does support 
the recommendations and commends the GAO for their diligence, we also 
take this opportunity to clarify several issues presented in the report 
in order to provide the most accurate information possible. 

Background: 

The Association of Air Medical Services (AAMS) is a non-profit trade 
association representing air ambulance and critical care transport 
service providers in the U.S. and across the globe. AAMS is comprised 
of over 300 air medical transport provider programs in the United 
States and Canada, staffed with over 50,000 highly skilled crew members 
(including medical directors, flight physicians, transport nurses, 
flight paramedics, helicopter and fixed wing pilots, mechanics, 
administrators and others) who have dedicated themselves to improving 
the health outcomes of the patients we serve. 

Air medicine has become a critically important part of our nation's 
health care delivery system, not only because air ambulance providers 
offer an ability to provide time-sensitive care, but also because their 
highly skilled crews and technologically advanced equipment allow them 
to provide a higher level of patient care ell-route than what is 
normally available via ground medical transport. Every 90 seconds, an 
air medical provider in the U.S. responds to a request to assist a 
critically ill or injured patient with a medically equipped and 
dedicated aircraft. 

AAMS and its members are firmly committed to assuring the public of 
access to this essential medical service while maintaining the highest 
level of safety in the delivery of patient care. To meet that 
commitment, AAMS and its members have worked extensively and 
collaboratively with the Federal Aviation Administration (FAA) 
Helicopter Emergency Medical Services (HEMS) Task Force and other 
regulatory entities in an effort to foster an environment that promotes 
a safe and effective air medical system. We firmly believe that this 
cooperative effort, combined with numerous safety initiatives of the 
air medical community, has led to a dramatic decrease in the number of 
HEMS accidents in 2006. 

Current Trends in the Air Medical Community: 

The air medical community is cognizant of and dedicated to the need for 
more thorough data collection, and to that end created the Atlas and 
Database of Air Medical Services (ADAMS), a voluntary database of air 
medical locations and other information which is referenced numerous 
times in the GAO's report. Support for ADAMS is provided by the US 
Department of Transportation (through the Federal Highway 
Administration and the National Highway Traffic Safety Administration). 
Through the voluntary reporting efforts of AAMS members, that database 
now represents the only accurate source for the locations, 
capabilities, and service areas for air medical programs and bases. 
This service is also being used by numerous government agencies, 
including the Department of Homeland Security, and remains the only 
source for information of this type. 

While the ADAMS database has become an excellent tool, it is also a 
voluntary database, and is therefore flawed when viewed from a 
historical perspective. Because it is a voluntary database, it is 
impossible to compare the number of helicopter services from 2003 (the 
first year of reporting into the database) and 2005 because those 
numbers may only reflect an increase in the number of companies and 
programs reporting into the database, not an actual increase in 
existing aircraft and service locations. While there is no doubt that 
the use of air medical services as a mode of patient transport has 
increased steadily throughout the community's history, the actual 
increase in numbers in the database is not completely reliable over 
time. 

It is equally problematic to compare the number of accidents in a 
certain period to the number of accidents in a different period; 
specifically, the number of accidents that occurred in the air medical 
industry in 1985 to the number of accidents that occurred in 2005. 
While the number of accidents is similar, the number of aircraft and 
hours being flown is dramatically different; in fact, AAMS estimates 
that the numbers of both aircraft and flight hours have increased ten 
fold from 1985 to 2005. So, while there can be no specific 
determination of an accident rate due to the fact that the data is not 
available in the aggregate, we can easily surmise that an estimated ten-
fold increase in both aircraft and flight hours with a similar number 
of accidents between 1985 and 2005 illustrates an industry with a 
vastly improved safety record over time. 

Air Medical Community Safety Initiatives: 

This is not to say, however, that there is any acceptable number of 
accidents in the air medical community. To that end, AAMS has 
instituted a number of safety-focused initiatives since 2000 as a way 
for our community to voluntarily address these issues. 

For instance, AAMS launched its Vision Zero initiative in March of 2005 
(www.aams.visionzero.or g). Vision Zero signifies zero accidents of 
consequence; it is our community's safety program designed to promote 
safety awareness by reaching the community with timely information and 
educational opportunities. Vision Zero, since its inception, has 
greatly increased safety awareness by creating a culture of intolerance 
to the loss of life and the suffering caused by the consequences of 
poor decision-making. It is a message that is carried through every 
conference, committee meeting, education session, and program activity 
carried out by the air medical community. We only hope to enhance the 
visibility and effectiveness of this program in the future. 

AAMS has also joined the International Helicopter Safety 
Team(www.ihst.org ), led by the American Helicopter Society (AHS), the 
Helicopter Association International (HAI), the FAA, and Transport 
Canada, to reduce helicopter accidents. These efforts are premised on 
the model that providers must work collaboratively with regulators to 
identify and accelerate the implementation of best practice standards, 
and they are both very closely coordinated with the work done by the 
FAA's HEMS Safety Task Force. 

AAMS represented the air medical community during the Part 135 Aviation 
Rulemaking Committee (ARC), the FAA's effort to engage the aviation 
industry during a re-write of Part 135 of the Federal Aviation 
Regulations (FAA's). The AAMS representatives sat on the steering 
committee and chaired the air medical subcommittee. The recommendations 
made by this group to the ARC included making all segments of a flight 
fall under the Part 135 regulations for rest and duty time and weather 
minima. It was also recommended to the ARC at that time to revise the 
existing Part 135 regulations to allow flights flying under Instrument 
Flight Rules (IFR) to off airport destinations without NWS approved 
weather stations. This change in the regulation would eliminate the 
need for any segment of a HEMS flight to operate under Part 91 as the 
current exemption requires. At present, the Part 135 ARC 
recommendations are being considered within the FAA for possible 
incorporation into regulatory changes. 

AAMS believes these examples, as well as our other initiatives, provide 
a faster, more flexible, and a more comprehensive means to improving 
safety. In an era in which both providers and regulators are working in 
increasingly resource-constrained environments, a collaborative, data 
driven strategy is essential. AAMS welcomes efforts to track these 
efforts and report on their efficacy. 

We further believe that the combination of these initiatives, a closely 
coordinated and cooperative effort, has led to the recent dramatic 
downturn of accidents in 2006, in which only three HEMS accidents 
occurred. While we firmly believe that any accident rate is 
unacceptable, we do believe that this dramatic decrease in the number 
of accidents is the direct result of the steps taken by the air medical 
community to improve safe operations. 

Improving Data Collection Concerning Air Medical Services: 

Improving the safety of medicine and medical transportation is a 
complex undertaking and cannot be studied in isolation. Air medicine 
must be seen as both a portion of the aviation community and as a 
necessary part of our medical system. Significant gaps in available 
data resources are evident and are a severe detriment to research 
efforts both from a medical and an aviation perspective. AAMS would 
like to support the GAO's recommendations in order to help the air 
medical community fill those gaps. Given the unique nature of and 
diverse models for the delivery of air medical transport in our country 
today, we recommend that any data collection effort involve all service 
providers - hospital-based services, independent services and 
government-operated services - in order to present a balanced and 
comprehensive picture of the community. 

Several AAMS members, often working through the non-profit Foundation 
for Air Medical Research and Education (FARE), conduct numerous 
research projects in order to determine what safety tools would be most 
effective. We firmly believe that these recommendations by the GAO can 
only help bolster the existing research and data-collection efforts and 
help provide the air medical community with the most valuable tools to 
improve and maintain safe operations. 

AAMS has also initiated, with the cooperation of the National Emergency 
Medical Services Operators Executive Forum, the voluntary collection of 
flight hour and other aviation data through a similar process as the 
collection of the ADAMS data. This data will be collected through the 
Center for Transportation and Injury Research and reported to the 
public in the aggregate. This program, dubbed the Flight Operations 
Database for Air Medical Services (FODAMS), is still in its infancy and 
the data could not be used for the purposes of this report. However, it 
is important to note that the air medical community has long recognized 
the importance of quality data, and has undertaken, through numerous 
efforts, the collection of this data voluntarily. 

AAMS and the air medical community are committed to improving safety of 
medicine and aviation; keeping those goals in mind, we also must 
continue to care for critically ill and injured patients every day. In 
our efforts to improve, we must not put more lives at risk by 
decreasing access to care. 

Air Medical Services as Part of the Emergency Medical System: 

While there are numerous flaws in the voluntary reporting of the data, 
there can be no doubt that the number of air medical services and 
medically equipped aircraft has increased, specifically in the last 
five years. Much of the growth in air medical services reflects a 
changing emergency healthcare system: as medical centers close 
emergency departments and trauma centers, especially in rural areas, 
the need for air transportation of the sickest and most badly injured 
patients greatly increases. The decreasing availability of specialized 
surgical resources, especially neurological, cardiac, and pediatric 
specialists, also drives the need for air medical transport, as time 
and distance to appropriate care have increased for large segments of 
our population. 

The Institute of Medicine (IOM) recently completed a landmark study of 
the emergency healthcare system in the United States, a portion of 
which is dedicated to our nation's emergency medical system. That 
report, entitled The Future of Emergency Care: Emergency Medical 
Services at the Crossroads highlights the necessity of air medical 
services in the emergency medical system, focusing on the ability of 
the HEMS to provide patient transport when time is of the essence. The 
report also highlights the growing necessity of the use of air medical 
services in inter-facility transport, moving severely injured or very 
ill patients to more appropriate specialty healthcare centers where 
they can be treated properly. 

The Institute of Medicine's report cited a study that claimed over 81 
million Americans now depend on air medical resources to reach needed 
care within the "golden hour" for trauma, cardiac, and other time 
sensitive emergencies, and over 40 million Americans who live in very 
rural areas remain underserved in the face of these time critical 
emergencies. It is clearly evident that air medical services now 
provide a critical access point in what many consider to be a failing 
medical system While we can only estimate the numbers of patients 
transported and cared for every year, or the amount of flight hours 
that were performed in the course of this operation, we can say with 
certainty that air medical transport has become a necessary and vital 
part of the medical system, both here in the United States and in many 
countries around the world. Medically equipped aircraft and specialized 
flight crews trained to meet the air medical mission are expensive 
investments that would not exist unless driven by a medical need; the 
changing emergency and specialized healthcare system in the United 
States is what provides that need. 

Air medical services have also played a key role in disaster response 
and emergency preparedness, transporting patients from the Pentagon 
following the 9/11 disaster, and more recently responding to Hurricanes 
Katrina and Rita in 2005. As noted in the US House of Representatives 
Final Report of the Select Bipartisan Committee to Investigate the 
Preparation for and Response to Hurricane Katrina, entitled A Failure 
of Initiative, air medical services were instrumental in much of the 
most critical hospital evacuations, especially in instances where 
hospitals were inaccessible by ground EMS providers. Over 60 civilian 
air medical helicopters transported thousands of affected citizens 
after Hurricane Katrina, despite the fact that there was a lack of 
communication and federal coordination of civilian aviation assets. 

Commercial air medical helicopters provide over 80% of the medical 
airlift capacity in our country, and are thus uniquely designed and 
equipped to address national emergencies involving very sick and 
critically injured patients. These aircraft are also very well suited 
to transporting critical patients out of a disaster area before the 
event occurs, as evidenced by the pre-evacuations to Hurricane Rita and 
the numerous hurricane responses in the state of Florida in which air 
medical helicopters are utilized both before and after a disastrous 
event. 

Transport medicine is among the most complex arenas of medicine, 
characterized by a dichotomy in which access to time sensitive care for 
critically ill and injured patients must be immediately available, 
often with limited planning time conducted in hostile environmental 
conditions. As Justice Oliver Wendell Holmes once noted: "to be safe 
does not mean to be risk free." Recognizing that risk cannot be 
completely eliminated, it is essential both for the public we serve, 
and the pilots, nurses, paramedics, physicians, and other health care 
providers who deliver care, that the practice environment be as safe as 
practically possible. AAMS and the air medical community remain 
committed to this ideal. 

AAMS would again like to thank the GAO for the opportunity to offer 
comments on this report. We also recognize and thank the Subcommittee 
on Aviation for their continued vigilance over the safety of the 
public, and we look forward to providing any further information that 
might be needed regarding our nation's critically important air medical 
mission. 

Sincerely, 

Signed by: 

Edward R. Eroe, CHE, CAE, CMTE: 
President, AAMS & Partner & CEO: 
MedServ Air Medical Transport, LLC Platte City, Missouri: 

Signed by: 

Dawn M. Mancuso, MAM, CAE: 
Executive Director/CEO: 
AAMS: 

[End of section] 

Appendix IV: GAO Contact and Staff Acknowledgments: 

GAO Contact: 

Gerald L. Dillingham, Ph.D., (202) 512-2834 or dillinghamg@gao.gov: 

Staff Acknowledgments: 

In addition to the contact named above, Nikki Clowers, Assistant 
Director; Ashley Alley; David Hooper; Brooke Leary; Heather MacLeod; 
Mitchell Karpman; Sara Ann Moessbauer; Stan Stenersen; Friendly Vang- 
Johnson; and Pamela Vines made key contributions to this report. 

(540123): 

FOOTNOTES 

[1] Such direct air carriers must also obtain an exemption from the 
Department of Transportation's economic regulatory authority, which is 
provided under 14 CFR Part 298. 

[2] For the purposes of this report, the use of the term "operator" 
refers to the FAA certificate holder. 

[3] Other types of operations include services that are operated by 
government entities or the military. For example, the Maryland State 
Police Aviation Division has a comprehensive helicopter air ambulance 
capability that covers the entire state, while the California Highway 
Patrol provides air ambulance services in portions of California. In 
addition to these public-use operators, federally operated aircraft 
provided by the U.S. Coast Guard and the U.S. Army conduct civilian air 
ambulance operations in select states. It is estimated that 10 percent 
of air ambulance operations in the United States are publicly operated. 
FAA does not have direct safety oversight responsibilities for public- 
use and military aircraft, and therefore, we did not include 
information on these types of operations in this report. 

[4] A hospital, or other non airline entity, may hold an exemption from 
DOT's economic authority to operate as an "indirect air carrier" (an 
entity that does not actually operate aircraft) to sell air ambulance 
air transport services directly to the public as a principal and, in 
turn, contract with a properly licensed airline for the air 
transportation. A blanket exemption authorizing such operations was 
issued in 1983 by the Civil Aeronautics Board, DOT's predecessor. Such 
indirect air carriers may not, however, mislead the public into 
thinking that they are airlines, which has been emphasized to the 
industry through a letter from DOT's Office of Aviation Enforcement to 
the Association of Air Medical Services. 

[5] Operating Requirements: Commuter and On Demand Operations and Rules 
Governing Persons on Board Such Aircraft, 14 C.F.R. pt. 135 (2006). 

[6] General Operating and Flight Rules, 14 C.F.R. pt. 91 (2006). 

[7] According to FAA officials, while Part 91 repositioning flights are 
not directly governed by Part 135 flight duty and rest requirements, 
there is little, if any, negative effect. 

[8] National Transportation Safety Board, Special Investigative Report 
on Emergency Medical Services Operations (Washington, D.C., 2006). 

[9] National Transportation Safety Board, Safety Study: Commercial 
Emergency Medical Services Helicopter Operations (Washington, D.C., 
1988). 

[10] AAMS is a nonprofit international association that serves 
providers of air and surface medical transport systems. 

[11] The Atlas and Database of Air Medical Services is compiled by 
CUBRC's Center for Transportation Injury Research in alliance with AAMS 
and the air medical industry, with support from the Federal Highway 
Administration and the National Highway Traffic Safety Administration. 
We did not independently assess the accuracy of these data for the 
purposes of this study. See appendix I for more information. 

[12] GAATAA is an annual survey of a sample of Part 135 on-demand and 
general aviation operators. FAA uses the survey data to evaluate the 
impact of safety initiatives and regulatory changes and for other 
purposes. 

[13] NTSB has previously recommended FAA require activity reporting for 
all Part 135 operators. 

[14] Based on the methodologies used, we recognize limitations with the 
estimates of flight hours, and our presentation is for the purposes of 
showing the wide range of estimates and the uncertainty associated with 
these estimates. Therefore, we did not assess the reliability of FAA or 
other estimates of flight hours for the purposes of this report. 

[15] Ira J. Blumen, M.D., and the University of Chicago Aeromedical 
Network, A Safety Review and Risk Assessment in Air Medical Transport: 
Supplement to the Air Medical Physician Handbook (November 2002). The 
methodology used in this study was updated in a follow-up study to 
include the nine largest air ambulance operators in the United States. 
For more information, see I.J. Blumen and D. Lees, "Air Medical Safety: 
Your First Priority," Principles and Direction of Air Medical Transport 
(Salt Lake City, Utah: Air Medical Physician Association, September 
2006). 

[16] For more information, see Bart Elias, Congressional Research 
Service, The Safety of Air Ambulances (Washington, D.C., 2006); and 
Matthew J. Rigsby, FAA, U.S. Civil Helicopter Emergency Medical 
Services Accident Data Analysis, the FAA Perspective (September 2005). 

[17] FARE's mission is to support the charitable, educational and 
research purposes of AAMS. 

[18] Balanced Budget Act of 1997, P.L. No. 105-33, § 4523 (Aug. 5, 
1997). 

[19] Bryan E. Bledsoe, "Thank You for Not Flying," Air and Space 
Journal (June/July 2006). 

[20] In 2006, FAA issued a letter to all state Emergency Medical 
Services Directors (or equivalent positions) describing "helicopter 
shopping" and requesting that the directors take action within their 
jurisdiction to implement standards and procedures to prohibit this 
practice. 

[21] NTSB defines an aviation accident as "an occurrence associated 
with the operation of an aircraft which takes place between the time 
any person boards the aircraft with the intention of flight and all 
such persons have disembarked, and in which any person suffers death or 
serious injury, or in which the aircraft receives substantial damage." 
An accident was included in the analysis as a helicopter air ambulance 
accident if (1) the accident involved a helicopter being operated by an 
air medical transport company and (2) the accident occurred during 
flight under either Part 91 or Part 135 regulations. All accidents 
involving public operators were excluded from our analysis. See 
appendixes I and II for more information about the accidents used in 
this analysis. 

[22] NTSB categorizes accidents by the highest level of injury 
sustained; therefore, accidents in which fatalities occurred could also 
include serious injuries, minor injuries, or no injuries. 

[23] Crew resource management is the effective management of resources 
to ensure that group members are operating from a common frame of 
reference and toward a common goal of safety. 

[24] The FAA also applies specific limitations and requirements for 
Part 135 operators through the use of operations specifications, which 
are individually developed for each operator. 

[25] Our analysis of NTSB data from 1998 through 2005 included 89 air 
ambulance helicopter accidents and 1,129 non-air-ambulance helicopter 
accidents. 

[26] FAA requires certificate holders to maintain a process for 
operational control of their aircraft. FAA officials noted that 
operational control should be (1) independent from the clinical or 
medical side of management and operations, (2) dictated solely by 
criteria such as weather and operational capability of crew and 
equipment, and (3) managed exclusively by the certificate holder. 

[27] For more information, see Matthew J. Rigsby, FAA, U.S. Civil 
Helicopter Emergency Medical Services Accident Data Analysis, the FAA 
Perspective (September 2005). 

[28] GAO, Aviation Safety: FAA Management Practices for Technical 
Training Mostly Effective; Further Actions Could Enhance Results, GAO-
05-728 (Washington, D.C.: Sept. 7, 2005). 

[29] FAA is shifting the oversight of commercial airlines (Part 121 
carriers) to a new system--the Air Transportation Oversight System--and 
as part of this realignment is restructuring the resources for 
geographic oversight. This restructuring may affect the availability of 
geographic resources for air ambulance oversight. 

[30] GAO, Aviation Safety: FAA's Safety Oversight System Is Effective 
but Could Benefit from Better Evaluation of Its Programs' Performance, 
GAO-06-266T (Washington, D.C.: Nov. 17, 2005). 

[31] Our analysis of NTSB accident data (see app. II) showed that more 
accidents occurred under Part 91 flight rules. However, because more 
flights take place under Part 91 rules, it is difficult to tie the 
accident record of Part 91 and Part 135 flights to safety. 

[32] FAA is considering a request from an air ambulance operator to 
perform instrument flight rules departures and approach procedures at 
airports and helipads that do not have an approved weather reporting 
source. If this exemption to current Part 135 rules is approved by FAA, 
this operator would be able to fly in accordance with instrument flight 
rules more often and, according to the operator, thereby improve the 
safety of its Part 135 flights. 

[33] SEP is used by FAA in its oversight of commuter air carriers and 
is considered to be a more effective and efficient surveillance program 
than traditional, event-based surveillance. SEP emphasizes a system 
safety approach of using risk analysis techniques and allows FAA 
inspectors to prioritize workload based on areas of highest risk. For 
more information on SEP, see GAO, Aviation Safety: System Safety 
Approach Needs Further Integration into FAA's Oversight of Airlines, 
GAO-05-726 (Washington, D.C.: Sept. 28, 2005). 

[34] FAA district offices have initiated hiring efforts to staff to 
target levels. 

[35] For the other large operators, inspection team sizes were 
increased from three nondedicated inspectors to four dedicated 
inspectors. 

[36] According to NTSB, as of December 21, 2006, these recommendations 
are still open. 

[37] NTSB, Current Procedures for Collecting and Reporting U.S. General 
Aviation Accident and Activity Data Safety Report (Washington, D.C., 
April 2005). 

[38] There is no clear consensus about what constitutes an air 
ambulance accident; thus, other studies may present different accident 
totals covering the same time period. 

[39] Large air ambulance markets were determined by state using the 
total number of bases and aircrafts as identified in the Atlas and 
Database of Air Medical Services. After states had been identified as 
having the greatest number of bases and aircrafts, metropolitan regions 
were chosen on the basis of having the greatest number of operators 
present in the area. 

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