This is the accessible text file for GAO report number GAO-09-627T 
entitled 'Aviation Safety: Potential Strategies to Address Air 
Ambulance Safety Concerns' which was released on April 22, 2009. 

This text file was formatted by the U.S. Government Accountability 
Office (GAO) to be accessible to users with visual impairments, as part 
of a longer term project to improve GAO products' accessibility. Every 
attempt has been made to maintain the structural and data integrity of 
the original printed product. Accessibility features, such as text 
descriptions of tables, consecutively numbered footnotes placed at the 
end of the file, and the text of agency comment letters, are provided 
but may not exactly duplicate the presentation or format of the printed 
version. The portable document format (PDF) file is an exact electronic 
replica of the printed version. We welcome your feedback. Please E-mail 
your comments regarding the contents or accessibility features of this 
document to 

This is a work of the U.S. government and is not subject to copyright 
protection in the United States. It may be reproduced and distributed 
in its entirety without further permission from GAO. Because this work 
may contain copyrighted images or other material, permission from the 
copyright holder may be necessary if you wish to reproduce this 
material separately. 


Before the Subcommittee on Aviation, Committee on Transportation and 
Infrastructure, House of Representatives: 

United States Government Accountability Office: 

For Release on Delivery: 
Expected at 10:00 a.m. EDT:
Wednesday, April 22, 2009: 

Aviation Safety: 

Potential Strategies to Address Air Ambulance Safety Concerns: 

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


GAO Highlights: 

Highlights of GAO-09-627T, a testimony before the Subcommittee on 
Aviation, Committee on Transportation and Infrastructure, House of 

Why GAO Did This Study: 

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

This testimony discusses (1) recent trends in the air ambulance 
industry with regard to its size, composition, and safety record; (2) 
recent industry and government efforts to improve air ambulance safety; 
and (3) potential strategies for improving air ambulance safety. This 
testimony is based primarily on GAO’s February 2007 study on air 
ambulance safety (GAO-07-353). To update and supplement this 2007 
report, GAO analyzed the latest safety information from NTSB and FAA, 
reviewed published literature on the state of the air ambulance 
industry, and interviewed FAA officials and industry representatives. 

GAO provided a copy of the draft testimony statement to FAA. FAA 
provided technical comments, which GAO incorporated as appropriate. 

What GAO Found: 

The air ambulance industry has increased in size, and concerns about 
its safety have grown in recent years. Available data suggest that the 
industry grew, most notably in the number of stand alone (independent 
or community-based) as opposed to hospital-based operators, and 
competition increased among operators, from 2003 through 2008. During 
this period, the number of air ambulance accidents remained at 
historical levels, fluctuating between 11 and 15 accidents per year, 
and in 2008, the number of fatal accidents peaked at 9. This accident 
record is cause for concern. However, a lack of reliable data on flight 
hours precludes calculation of the industry accident rate—a critical 
piece of information in determining whether the increased number of 
accidents reflects industry growth or a declining safety record. 

The air ambulance industry and FAA have acted to address accident 
trends and causes. For example, FAA enhanced its oversight to reflect 
the varying sizes of operators, provided technical resources to the 
industry, launched an accident mitigation program, and revised the 
minimum standards for weather and safe cruising altitudes that apply to 
air ambulance operations. 

Despite the actions to improve air ambulance safety, 2008 was the 
deadliest year on record for the industry. Through its work on aviation 
safety, including air ambulance safety; review of the published 
literature; and interviews with government and industry officials, GAO 
has identified several potential strategies for improving air ambulance 
safety, including the following: 

* Obtain complete and accurate data on air ambulance operations. 

* Increase the use of safety technologies. 

* Sustain recent efforts to improve air ambulance safety. 

* Fully address NTSB’s recommendations. 

* Adopt safety management systems within the air ambulance industry. 

* Clarify the role of states in overseeing air medical services. 

* Determine the appropriate use of air ambulance services. 

Figure: Air Ambulance Helicopters: 

[Refer to PDF for image: two photographs] 

Source: FEMA and Washington State Department of Health. 

[End of figure] 

[End of section] 

Mr. Chairman and Members of the Subcommittee: 

I appreciate the opportunity to testify before you today on air 
ambulance safety. My remarks will focus on (1) recent trends in the air 
ambulance industry with regard to size, composition, and safety record; 
(2) recent industry and government efforts to improve air ambulance 
safety; and (3) potential strategies for improving air ambulance 
safety. My testimony is based primarily on our February 2007 report on 
air ambulance safety, which we conducted at the request of the 
Chairman.[Footnote 1] To update and supplement our existing work, we 
analyzed the latest safety information from the National Transportation 
Safety Board (NTSB) and the Federal Aviation Administration (FAA), 
reviewed published literature on the state of the air ambulance 
industry, and interviewed officials from NTSB and FAA and industry 
representatives.[Footnote 2] We conducted this work in March and April 


Air ambulances are an integral part of U.S. emergency medical systems, 
primarily transporting patients between hospitals, but also providing 
transport from accident scenes or for organs, medical supplies, and 
specialty medical teams. Air ambulances may be helicopters or fixed- 
wing aircraft. Helicopter air ambulances provide on-scene responses and 
much of the shorter-distance hospital-to-hospital transport, while 
fixed-wing aircraft are used mainly for longer facility-to-facility 
transport. (See figure 1.) Helicopter air ambulances make up about 74 
percent of the air ambulance fleet and, unlike fixed-wing aircraft, do 
not always operate under the direction of air traffic controllers. They 
also often operate in challenging conditions, flying, for example, at 
night during inclement weather and using makeshift landing zones at 
remote sites. My testimony today focuses on the safety of helicopter 
air ambulance operations. 

Figure 1: Air Ambulance Helicopter: 

[Refer to PDF for image: photograph] 

Source: Clare McLean © 2006. 

[End of figure] 

Air ambulance operations can take many different forms but are 
generally one of two business models--hospital-based or stand-alone. 
[Footnote 3] In a hospital-based model, a hospital typically provides 
the medical services and staff and contracts with an aviation services 
provider for pilots, mechanics, and aircraft. The aviation services 
provider also holds the FAA operating certificate. The hospital pays 
the operator for services supplied.[Footnote 4] In a stand-alone 
(independent or community-based) model, an independent operator sets up 
a base in a community and serves various facilities and localities. 
Typically, the operator holds the FAA operating certificate and either 
employs both the medical and flight crews or contracts with an aviation 
services provider for them. This stand-alone model carries more 
financial risk for the operator because revenues depend solely on 
payments for transporting patients. Some operators provide both 
hospital-based and stand-alone services and may have bases located over 
wide geographic areas. 

Regardless of the business model employed, most air ambulances--except 
government and military aircraft--must operate under rules specified in 
Part 135 of Title 14 of the Code of Federal Regulations when patients 
are on board and may operate under rules specified in Part 91 when 
patients are not present. As a result, different legs of air ambulance 
missions may be flown under different rules. However, some operators 
fly under part 135 regardless of whether patients are on board the 
aircraft. (See figure 2.) Flight rules under Parts 91 and 135 differ in 
two key areas--(1) minimum requirements for weather and visibility and 
(2) rest requirements for pilots. The Part 135 requirements are more 

Figure 2: Air Ambulance Scene Response Flight Legs: 

[Refer to PDF for image: illustration] 

* Reposition (Part 91); 
* En Route (Part 91); 
* Transport (Part 135). 

Source: GAO. 

Note: Flight rules under Parts 91 and 135 differ in two key areas--(1) 
minimum requirements for weather and visibility and (2) rest 
requirements for pilots. The Part 135 requirements are more stringent. 

[End of figure] 

Industry Has Expanded and Safety Concerns Have Grown in Recent Years: 

Available Data Suggest Industry Growth and Increased Competition: 

According to industry experts and observers, the air ambulance industry 
has grown, but data limitations make it difficult to determine by how 
much. Data for several years on the number of aircraft and number of 
operating locations are available in a database maintained by the 
Calspan-University of Buffalo Research Center (CUBRC) in alliance with 
the Association of Air Medical Services (AAMS).[Footnote 5] For 2003, 
the first year for which data are available, AAMS members reported a 
total of 545 helicopters stationed at 472 bases (airports, hospitals, 
and helipads). By 2008, the number of helicopters listed in the 
database had grown to 840, an increase of 54 percent, and the number of 
bases had grown to 699, an increase of 48 percent (see fig. 3). While a 
database official said that the data partly reflect the use of a 
revised criterion that allowed for the inclusion of more helicopters 
and for improved reporting since the database was established, the 
increase also reflects actual growth. 

Figure 3: Number of Air Ambulance Bases and Aircraft, 2003 through 

[Refer to PDF for image: multiple vertical bar graph] 

Year: 2003; 
Bases: 472; 
Aircraft: 545. 

Year: 2004; 
Bases: 546; 
Aircraft: 658. 

Year: 2005; 
Bases: 614; 
Aircraft: 753. 

Year: 2006; 
Bases: 647; 
Aircraft: 792. 

Year: 2007; 
Bases: 664; 
Aircraft: 810. 

Year: 2008; 
Bases: 699; 
Aircraft: 840. 

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

[End of figure] 

Data are less readily available on whether this increase number of 
aircraft translates into an increased number of operating hours. FAA 
does not collect flight-hour data from air ambulance operators. Unlike 
scheduled air carriers, which are required to report flight hours, air 
ambulance operators and other types of on-demand operators regulated 
under Part 135 are not required to report flight activity data to FAA 
or the Department of Transportation.[Footnote 6] Historically, FAA 
estimated the number of flight hours, using responses to its annual 
General Aviation and Air Taxi and Avionics (GAATAA) survey. These 
estimates may not be reliable, however, because the survey is based on 
a sample of aircraft owners and response rates have historically been 

According to the government and industry officials we interviewed and 
the literature we reviewed, most of the air ambulance industry's growth 
has been in the stand-alone (independent) provider business model. 
[Footnote 7] Testimony from industry stakeholders recently submitted to 
NTSB further identifies the stand-alone provider business model as the 
current area of industry growth. The growth in the stand-alone provider 
business model has led to increased competition in some locales. 
According to the officials we interviewed and others who have studied 
the industry, the increase in the stand-alone provider business model 
is linked to the development, mandated in 1997, of a Medicare fee 
schedule for ambulance transports, which has increased the potential 
for profit making.[Footnote 8] This fee schedule was implemented 
gradually starting in 2002, and since January 2006, 100 percent of 
payments for air ambulance services have been made under the fee 
schedule.[Footnote 9] Because the fee schedule has created the 
potential for higher and more certain revenues, competition has 
increased in certain areas, according to many of our sources. 

Increased competition can lead to potentially unsafe practices, 
industry experts said. Although we were unable to determine how 
widespread these activities are, experts cited the potential for such 
practices, including helicopter shopping and call jumping. Helicopter 
shopping refers to calling a series of operators until an operator 
agrees to take a flight assignment, without telling the subsequently 
called operators why the previously called operators declined the 
flight. This practice can be unsafe if the operator that accepts the 
flight assignment is not aware of all of the facts surrounding the 
assignment.[Footnote 10] Call jumping occurs when an air ambulance 
operator responds to a scene without being dispatched to it or when 
multiple operators are summoned to an accident scene. This situation is 
potentially dangerous because the aircraft are all operating in the 
same uncontrolled airspace--often at night or in marginal weather 
conditions--increasing the risk of a midair collision or other 

Industry Experienced Highest Number of Fatal Accidents in 2008, but 
Data Limitations Preclude Complete Understanding of Safety Record: 

From 1998 through 2008, the air ambulance industry averaged 13 
accidents per year, according to NTSB data.[Footnote 11] The annual 
number of air ambulance accidents increased from 8 in 1998 to a high of 
19 in 2003. Since 2003, the number of accidents has slightly declined, 
fluctuating between 11 and 15 accidents per year. While the total 
number of air ambulance accidents peaked in 2003, the number of fatal 
accidents peaked in 2008, when 9 fatal accidents occurred (see fig. 4). 
Of 141 accidents that occurred from 1998 to 2008, 48 accidents resulted 
in the deaths of 128 people. From 1998 through 2007, the air ambulance 
industry averaged 10 fatalities per year. The number of overall 
fatalities increased sharply in 2008, however, to 29. 

Figure 4: Fatal and Non-fatal Air Ambulance Accidents, 1998-2008: 

[Refer to PDF for image: multiple line graph] 

Year: 1998; 
Fatal accidents: 4; 
Non-fatal accidents: 4. 

Year: 1999; 
Fatal accidents: 3; 
Non-fatal accidents: 6. 

Year: 2000; 
Fatal accidents: 4; 
Non-fatal accidents: 9. 

Year: 2001; 
Fatal accidents: 2; 
Non-fatal accidents: 12. 

Year: 2002; 
Fatal accidents: 5; 
Non-fatal accidents: 8. 

Year: 2003; 
Fatal accidents: 4; 
Non-fatal accidents: 15. 

Year: 2004; 
Fatal accidents: 6; 
Non-fatal accidents: 7. 

Year: 2005; 
Fatal accidents: 6; 
Non-fatal accidents: 9. 

Year: 2006; 
Fatal accidents: 3; 
Non-fatal accidents: 10. 

Year: 2007; 
Fatal accidents: 2; 
Non-fatal accidents: 8. 

Year: 2008; 
Fatal accidents: 9; 
Non-fatal accidents: 2. 

Source: GAO analysis of NTSB data. 

Note: These numbers include accidents of public-use aircraft as well as 
additional accidents for 1998 through 2005 that NTSB included in its 
totals after revising its definition of an air ambulance accident. 

[End of figure] 

Both the spike in the number of fatal accidents in 2008 and the overall 
number of accidents are a cause for concern. However, given the 
apparent growth in the industry, the increase in the number of 
accidents may not indicate that the industry has experienced, on the 
whole, the industry's safety record has worsened. More specifically, 
without actual data on the number of hours flown, no accident rate can 
be accurately calculated. Because an accurate accident rate is 
important to a complete understanding of the industry's safety, we 
recommended in 2007 that FAA collect data on flight activity, including 
flight hours.[Footnote 12] In response, FAA has surveyed all helicopter 
air ambulance operators to collect flight activity data. However, to 
date, FAA's survey response rate is low, raising questions about 
whether this information can serve as an accurate measure or indicator 
of flight activity. 

In the absence of actual flight activity data, others have attempted to 
estimate flight hours and accident rates for the industry. For example, 
an Air Medical Physician Association (AMPA) study estimated annual 
flight hours for the air medical industry through an operator survey, 
determining that the overall air medical helicopter accident rate has 
dropped slightly in recent years to approximately 3 accidents per 
100,000 flight hours.[Footnote 13] However, the study's preliminary 
estimates for 2008 indicate that the fatal accident rate tripled over 
the 2007 rate, increasing from 0.54 fatal accidents per 100,000 flight 
hours in 2007 to 1.8 fatal accidents per 100,000 flight hours in 2008. 

Data on the causes and factors underlying air ambulance accidents 
indicate that while the majority of accidents are caused by pilot 
error, a number of risks, including nighttime operations, adverse 
weather conditions, and flights to remote sites, also contribute to 
accidents. NTSB data on helicopter accidents occurring from 1998 
through 2008 show that pilot error was deemed the probable cause in 
more than 70 percent of air ambulance accidents, while factors related 
to flight environment (such as light, weather, and terrain) contributed 
to 54 percent of all accidents.[Footnote 14] Nighttime accidents for 
air ambulance helicopters were prevalent, and air ambulance accidents 
tended to be more severe when they occurred at night than during the 
day. Similarly, air ambulance accidents were often associated with 
adverse weather conditions (e.g., wind gust and fog). Finally, flying 
to remote sites may further expose the crew to other risks associated 
with unfamiliar topography and makeshift landing sites. 

Industry and FAA Have Acted to Address Air Ambulance Accident Trends 
and Causes: 

Increase in Number of Accidents Has Led to Greater Industry Focus on 

In 2007, we reported that the air ambulance industry's response to the 
higher number of accidents has taken a variety of forms, including 
research into accident causes and training.[Footnote 15] Since then, 
the industry has continued its focus on improving safety by, for 
example, initiating efforts to develop an industry risk profile and 
share weather information. In July 2008, for instance, AAMS convened a 
conference (summit) on safety to encourage open communication between 
the medical and aviation sectors of the industry. AAMS plans to issue a 
summary of the summit's proceedings that will include recommended next 
steps. Table 1 highlights examples of recent industry initiatives. 

Table 1: Examples of Recent Air Ambulance Industry Initiatives to 
Address Safety Concerns: 

Year: 2007; 
Organization: AirMed International LLC; 
Initiative: Administers the Web Site, which allows 
medical transport programs to share current information on delays or 
cancellations due to weather. 

Year: 2008; 
Organization: AAMS; 
Initiative: Safety summit with operators, regulators, medical 
professionals, and insurance providers to discuss and learn from recent 

Year: 2008; 
Organization: Commission on the Accreditation of Medical Transport 
Systems (CAMTS); Initiative: Produced and distributed a video on 
"helicopter shopping," which can lead to an unsafe condition in which 
an operator initiates a flight that it may have declined if it had been 
told that other operators had turned down the flight for safety 

Year: 2008; Organization: Bell Helicopter; Initiative: Sponsored safety 
risk profile of the industry.. 

Year: 2009; 
Organization: Air Medical Operators Association (AMOA), AAMS, and 
Helicopter Association International; Initiative: Developed and 
submitted recommendations to NTSB that are intended to enhance air 
medical safety. 

Source: GAO. 

[End of table] 

FAA Has Taken a Number of Actions to Address Safety Concerns: 

In 2007, we reported that FAA, the primary federal agency overseeing 
air ambulance operators, has issued guidance, expanded inspection 
resources, and collaborated with the industry to reduce the number of 
air ambulance accidents. Since then, FAA has taken additional steps to 
improve air ambulance safety including the following: 

* Enhanced oversight to better reflect the unique nature of the 
industry. FAA has changed its oversight to reflect the varying sizes of 
operators. Specifically, large operators with 25 or more helicopters 
dedicated to air medical flights are now assigned to dedicated FAA 
Certificate Management Teams (CMT)--groups of inspectors that are 
assigned to one air ambulance operator. These CMTs range in size from 4 
inspectors for Keystone Helicopter Corporation, which has a fleet of 38 
helicopters, to 24 inspectors for Air Methods, which has a fleet of 322 
helicopters. Additionally, CMTs use a data-and risk-based process to 
target inspections to areas that pose greater safety risk. For 
operators of all sizes, FAA has asked inspectors to consider using the 
Surveillance Priority Index tool, which can be used to identify an 
operator's most pressing safety hazards. In addition, FAA is hiring 
more aviation safety inspectors with rotorcraft experience. 

* Provided technical resources. FAA has revised its guidance for the 
use of night vision goggles (NVG) and established a cadre of NVG 
national resource inspectors.[Footnote 16] FAA has also developed 
technical standards for the manufacture of helicopter terrain awareness 
and warning systems for air medical helicopters.[Footnote 17] These 
standards articulate the minimum performance standards and 
documentation requirements that the technology must meet to obtain FAA 
approval. FAA also commissioned the development of an air ambulance 
weather tool, which provides weather assessments for the community. 
[Footnote 18] 

* Launched accident mitigation program. Initiated in January 2009, this 
program provides guidance for inspectors of air ambulance operators, 
requiring them to ensure, among other things, that these operators have 
a process in place to facilitate safe operations, such as a risk 
assessment program. 

* Revised minimum standards for weather and safe cruise altitudes: To 
enhance safety, FAA revised its minimal requirements for weather and 
safe cruise altitudes for helicopter air ambulances in November 2008. 
[Footnote 19] Specifically, FAA revised its specifications to require 
that if a patient is on board for a flight or flight segment and at 
least one of the flight segments is therefore subject to Part 135 
rules, then all of the flight segments must be conducted within the 
revised weather minimums and above a minimum safe cruise altitude 
determined in preflight planning. 

* Issued guidance on operational control: To help operators better 
assess risk, improve the flow of information before and during flights, 
and increase support for flight operations, FAA issued guidance to help 
air medical operators develop, implement, and integrate operations 
control centers and enhance operational control procedures.[Footnote 

To date, FAA has opted not to use its rulemaking authority to require 
certain actions, relying instead on notices and guidance to encourage 
air ambulance operators to take certain actions. FAA guidance and 
notices are not mandatory for air ambulance operators and are not 
subject to enforcement. FAA officials told us that rulemaking is a time-
consuming process that can take years to complete, hindering the 
agency's ability to quickly respond to emerging issues. By issuing 
guidance rather than regulations, FAA has been able to quickly respond 
to concerns about air ambulance safety. However, we previously noted 
that FAA lacked information on the extent to which air ambulance 
operators were implementing the agency's voluntary guidance and on the 
effect such guidance was having. Consequently, we recommended that FAA 
collect information on operators' implementation of the voluntary 
guidance and evaluate the effectiveness of that guidance. In response, 
in January 2009, FAA directed safety inspectors to survey the air 
medical operators they oversee about their adoption of suggested 
practices, such as implementing risk assessment programs and developing 
operations control centers.[Footnote 21] According to the inspectors, 
most of the 74 operators surveyed said they had adopted these 

Potential Strategies for Improving Air Ambulance Safety: 

Despite the actions taken by the industry and the federal government, 
2008 was the deadliest year on record for the air ambulance industry. 
As a board member noted at the recent NTSB hearing on air ambulance 
safety, the recent accident record of the industry is unacceptable. 
Based on our body of work on aviation safety, including air ambulance 
safety; a review of the published literature; and interviews with 
government and industry officials, we have identified several potential 
strategies for improving air ambulance safety. Each of these strategies 
has merits and challenges, and we have not analyzed their benefits and 
costs. But, as the recent accident numbers show, additional efforts are 

* Obtain complete and accurate data on air ambulance operations: As we 
reported in 2007, FAA lacks basic industry information, such as the 
number of flights and flight hours. In response to our prior 
recommendation that FAA collect flight activity data, FAA surveyed all 
helicopter air ambulance operators in 2008, but fewer than 40 percent 
responded, thereby raising questions about the reliability of the 
information collected. The low response rate also suggests that many 
operators will not provide this information unless they are required to 
do so. Until FAA obtains complete and reliable information from all air 
ambulance operators, it will be unable to gain a complete understanding 
of the industry and determine whether its efforts to improve industry 
safety are sufficient and accurately targeted. 

* Increase use of safety technologies: We have previously reported that 
using appropriate technology and infrastructure can help improve 
aviation safety.[Footnote 22] For example, the development and 
installation of terrain awareness and warning systems on large 
passenger carriers has almost completely eliminated controlled flights 
into terrain,[Footnote 23] particularly for aircraft equipped with this 
system. When we studied the air ambulance industry in 2006 and 2007, 
the most frequently cited helicopter-appropriate technology was night 
vision goggles. Additional safety technology has been developed or is 
in development that will help aircraft avoid cables and enhance terrain 
awareness for pilots, among other things. However, testimony submitted 
by industry stakeholders at NTSB's February 2009 hearing on air 
ambulance safety indicated that the implementation of such technology 
has been slow. NTSB previously recommended that FAA require terrain 
awareness and warning systems on air ambulances. Proposed legislation 
(H.R. 1201) would also require FAA to complete a study within one year 
of the date of enactment on the feasibility of requiring flight data 
and cockpit voice recorders on new and existing air ambulances. 
[Footnote 24] 

* Sustain recent efforts to improve air ambulance safety: Our past 
aviation safety work and anecdotal information on air ambulance 
accident trends suggest that the industry and federal government must 
sustain recent efforts to improve air ambulance safety. In 1988, after 
the number of accidents increased in the mid-1980s, NTSB published a 
study that examined air ambulance safety issues.[Footnote 25] The study 
contained 19 safety recommendations to FAA and others. FAA took action, 
including implementing the NTSB recommendations, and the number of 
ambulance accidents declined in the years that immediately 
followed.[Footnote 26] However, as time passed, the number of accidents 
started to increase, peaking in 2003. This again triggered a flurry of 
government and industry actions. Similarly, FAA took steps to address 
runway incursions and overruns after the number and rate of incursions 
peaked in fiscal year 2001, but FAA's efforts later waned, and the 
number and rate of incursions and overruns remained steady. [Footnote 

* Fully Address NTSB recommendations: In 2006, NTSB published a special 
report focusing on the air ambulance industry, which included four 
recommendations to FAA to improve air ambulance safety.[Footnote 28] 
Specifically, NTSB called for FAA to (1) require that all flights with 
medical personnel on board be conducted in accordance with Part 135 
regulations, (2) develop and implement flight risk evaluation programs, 
(3) require formalized dispatch and flight-following procedures, and 
(4) require terrain awareness and warning systems on aircraft. As of 
January 2009, FAA had sufficiently addressed only the recommendation to 
require formalized dispatch and flight-following procedures, according 
to NTSB. However, NTSB's February 2009 air ambulance hearing 
highlighted the status of the NTSB recommendations, and major industry 
associations have said they agree in principle with the 
recommendations, but would like to work with FAA and NTSB to adapt the 
recommendations to the industry's circumstances and gain more 
flexibility. Proposed legislation (H.R. 1201) also would require most 
of the safety enhancements NTSB recommended. 

* Adopt safety management systems within the air ambulance industry: 
Air operators rely on a number of protocols to help reduce the 
potential for poor or erroneous judgment, but evidence suggests that 
these protocols may be inconsistently implemented or followed in air 
ambulance operations. According to an FAA report on air ambulance 
accidents from 1998 through 2004, a lack of operational control 
(authority over initiating, conducting, and terminating a flight) and 
poor aeronautical decision making were significant factors contributing 
to these accidents.[Footnote 29] To combat such issues, FAA has been 
encouraging air ambulance operators to move toward adopting safety 
management systems, providing guidance, developing a generic flight 
risk assessment tool for operators, and requiring inspectors to promote 
the adoption of safety best practices. 

* Clarify the role of states in overseeing air ambulance services: Air 
ambulance industry stakeholders disagree on the role that states should 
play in overseeing broader aspects of air medical operations. In 
particular, some industry stakeholders have advocated a greater role 
for states in regulating air ambulance services as part of their public 
health function. Other industry stakeholders, however, oppose increased 
state oversight, noting, for example, that the Airline Deregulation Act 
explicitly prohibits states from regulating the price, route, or 
service of an air carrier. This legislation generally limits oversight 
at the state or local levels to the medical care and equipment provided 
by air ambulance services, although the extent of this oversight varies 
by state. Proposed legislation (H.R. 978) would recognize and clarify 
the authority of the states to regulate intrastate air ambulance 
services in accordance with their authority over public health. 
[Footnote 30] 

* Determine the appropriate use of air ambulance services: According to 
a May 2007 article by two physicians, multiple organizations are 
concerned that air ambulance services are overused and misused. 
[Footnote 31] The study further notes concerns that decisions about 
where to transport a patient may be influenced by nonmedical reasons, 
such as insurance coverage or agreements with hospitals. Another 
industry expert has posited that excessive use of air ambulances may be 
unsafe and not beneficial for most patients, citing recent studies that 
conclude few air transport patients benefited significantly over 
patients transported by ground and noting the recent increase in the 
number of air medical accidents. Other studies, however, have disagreed 
with this position, citing reductions in mortality achieved by using 
air ambulances to quickly transport critically injured patients. 

Agency Comments: 

We provided a draft copy of this testimony to FAA for review and 
comment. FAA provided technical clarifications, which we incorporated 
as appropriate. 

Mr. Chairman, this concludes my prepared statement. I would be pleased 
to respond to questions from you or other Members of the Subcommittee. 

GAO Contact and Staff Acknowledgments: 

For further information on this statement, please contact Dr. Gerald L. 
Dillingham at (202) 512-2834 or Contact points for 
our Congressional Relations and Public Affairs offices may be found on 
the last page of this statement. Individuals making key contributions 
to this testimony were Nikki Clowers, Assistant Director; Vashun Cole, 
Elizabeth Eisenstadt, Brooke Leary, and Pamela Vines. 

[End of section] 


[1] GAO, Aviation Safety: Improved Data Collection Needed for Effective 
Oversight of Air Ambulance Industry, [hyperlink,] (Washington, D.C.: Feb. 21, 
2007). This review and our updated work was conducted in accordance 
with generally accepted government auditing standards. 

[2] FAA is the federal agency responsible for providing aviation safety 
oversight in the United States and NTSB is an independent federal 
agency charged with investigating each U.S. aviation accident. 

[3] Other types of operations include services that are operated by 
government entities or the military. 

[4] A hospital, or other nonairline entity, may hold an exemption from 
the Department of Transportation to operate as an "indirect air 
carrier," that is, an entity that does not actually operate aircraft, 
to sell air ambulance air services to the public and contract with a 
licensed airline for the air transportation. 

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

[6] NTSB previously recommended that FAA require flight activity 
reporting for all Part 135 operators. 

[7] For example, a 2006 public policy paper by the Foundation for Air 
Medical Research & Education (FARE) observed that many air medical 
services "had become independent, community based resources." 
Similarly, a 2005 FAA research paper noted that "the fastest growing 
segment of the [air medical] industry is the independent provider. 

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

[9] Prior to 2002, all ambulance service reimbursements by Medicare 
were based on the type of provider. 

[10] For example, in July 2004, an air ambulance collided with trees 
shortly after take-off, killing the pilot, flight nurse, flight 
paramedic, and patient. Three other air ambulance operators had 
previously turned down this same flight, including one that had 
attempted it but was forced to return because of fog. The pilot during 
the accident, however, was not informed by emergency medical service 
dispatchers that other pilots had declined the flight because of 
adverse weather conditions. In 2006, FAA issued a letter to all state 
Emergency Medical Services Directors (or equivalent positions) 
describing "helicopter shopping" and requesting that the directors take 
action within their jurisdiction to implement standards and procedures 
to prohibit this practice. 

[11] NTSB has revised its definition of an air ambulance accident since 
our 2007 report to include accidents with an aircraft (1) dedicated to 
air medical operations, (2) configured for such operations, and (3) 
piloted by a dedicated air medical flight crew. Consequently, the 
numbers of accidents presented in this testimony for 1998 through 2005 
is slightly higher than those presented in our 2007 report. 

[12] [hyperlink,]. 

[13] Ira J. Blumen, M.D., and the University of Chicago Aeromedical 
Network, A Safety Review and Risk Assessment in Air Medical Transport: 
Supplement to the Air Medical Physician Handbook (November 2002). The 
methodology used in this study was updated in a follow up study to 
include the nine largest air ambulance operators in the United States. 
To determine flight hours, the study's author multiplied the average 
flight hours per program by the total number of programs identified in 
each year. For more information, see I.J. Blumen and D. Lees, "Air 
medical Safety: Your First Priority" Principles and Direction of Air 
Medical Transport (Salt Lake City, Utah: Air Medical Physician 
Association, September 2006). The methodology was further expanded 
following the 2006 study to include nearly 20 operators, representing a 
reported 90 percent of air medical helicopters in the United States. 
I.J. Blumen, "An Analysis of HEMS Accidents and Accident Rates" 
(Washington, D.C.: NTSB public hearing: Safety of Helicopter Emergency 
Medical Services Operations, February, 2009). We interviewed Dr. Blumen 
about the study's methodology and findings. We determined that the 
study's methodology and findings were sufficiently reliable for our 

[14] Numbers do not add to 100 percent because multiple factors could 
contribute to a single accident. Some 2008 accidents were excluded from 
this analysis because NTSB has not yet completed their accident 
investigations and made determinations of cause and underlying factors. 

[15] For more information on the industry safety initiatives we 
identified, see [hyperlink,]. 

[16] See FAA Order 8900.1 and Notice 8000.349. 

[17] TSO-C194, December 17, 2008. 

[18] Developed as a result of FAA's 2006 air ambulance weather summit, 
the air ambulance weather tool provides assessments of ceilings and 
visibility for a given time and location. It does not report 
observations or forecasts and currently can only be used in visual 
flight rule operations to determine whether to initiate a flight. 

[19] 73 Fed. Reg. 6754, Nov. 14, 2008. 

[20] Advisory Circular 120-96. 

[21] See FAA Notice 8900.63. 

[22] GAO, Aviation Runway and Ramp Safety: Sustained Efforts to Address 
Leadership, Technology, and Other Challenges Needed to Reduce Accidents 
and Incidents, [hyperlink,] 
(Washington, D.C.: Nov. 20, 2007. 

[23] Controlled flight into terrain occurs when an airworthy aircraft 
under the control of the flight crew is flown unintentionally into 
terrain, obstacles or water, usually with no prior awareness by the 

[24] H.R. 1201, "Air Medical Safety Act." The bill would also require a 
complete rulemaking within 30 months requiring flight data and cockpit 
voice recorders on board air ambulances. 

[25] NTSB, Safety Study: Commercial Emergency Medical Services 
Helicopter Operations (Washington, D.C.: 1988). 

[26] Because of the lack of flight activity data and the number of 
other factors that could affect accident trends, we do not know to what 
extent, if at all, FAA's actions contributed to the decline in the 
number of accidents. 

[27] [hyperlink,]. 

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

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

[30] H.R. 978, "Helicopter Medical Services Patient Safety, Protection, 
and Coordination Act." 

[31] Mary E. Fallat, MD, FACS, and John Overton, MD et al, "Air Medical 
Transport Safety," Bulletin of the American College of Surgeons, May 

[End of section] 

GAO's Mission: 

The Government Accountability Office, the audit, evaluation and 
investigative arm of Congress, exists to support Congress in meeting 
its constitutional responsibilities and to help improve the performance 
and accountability of the federal government for the American people. 
GAO examines the use of public funds; evaluates federal programs and 
policies; and provides analyses, recommendations, and other assistance 
to help Congress make informed oversight, policy, and funding 
decisions. GAO's commitment to good government is reflected in its core 
values of accountability, integrity, and reliability. 

Obtaining Copies of GAO Reports and Testimony: 

The fastest and easiest way to obtain copies of GAO documents at no 
cost is through GAO's Web site [hyperlink,]. Each 
weekday, GAO posts newly released reports, testimony, and 
correspondence on its Web site. To have GAO e-mail you a list of newly 
posted products every afternoon, go to [hyperlink,] 
and select "E-mail Updates." 

Order by Phone: 

The price of each GAO publication reflects GAO’s actual cost of
production and distribution and depends on the number of pages in the
publication and whether the publication is printed in color or black and
white. Pricing and ordering information is posted on GAO’s Web site, 

Place orders by calling (202) 512-6000, toll free (866) 801-7077, or
TDD (202) 512-2537. 

Orders may be paid for using American Express, Discover Card,
MasterCard, Visa, check, or money order. Call for additional 

To Report Fraud, Waste, and Abuse in Federal Programs: 


Web site: [hyperlink,]: 
Automated answering system: (800) 424-5454 or (202) 512-7470: 

Congressional Relations: 

Ralph Dawn, Managing Director, 
(202) 512-4400: 
U.S. Government Accountability Office: 
441 G Street NW, Room 7125: 
Washington, D.C. 20548: 

Public Affairs: 

Chuck Young, Managing Director, 
(202) 512-4800: 
U.S. Government Accountability Office: 
441 G Street NW, Room 7149: 
Washington, D.C. 20548: