The Safety of Air Ambulances

Order Code RL33430

CRS Report for Congress

Received through the CRS Web

The Safety of Air Ambulances

May 23, 2006

/name redacted/

Specialist in Aviation Safety, Security, and Technology

Resources, Science, and Industry Division

Congressional Research Service ˜ The Library of Congress

The Safety of Air Ambulances

Summary

The estimated rate of air ambulance accidents has been steadily rising since the

early 1990s, and has increased at a rapid rate since 1998 when the industry began to

expand more rapidly and shift toward a model of more independent private air

ambulance services that cover larger geographic areas. Statistics indicate that the

large majority of air ambulance accidents are attributable to operational factors

related to pilot situation awareness and decision making when faced with adverse

environmental conditions such as darkness, deteriorating weather, rugged terrain, or

some combination of these factors.

Initiatives to improve air ambulance safety to date have consequently focused

on additional pilot training, implementing risk management practices to improve the

safety of flight operations, and using various technologies to improve pilot situation

awareness in restricted visibility conditions. However, implementation of these

safety measures has strictly been voluntary. The National Transporation Safety

Board (NTSB) and other aviation safety experts are advocating the mandatory use of

formal flight dispatch procedures and risk management practices among air

ambulance operators as well as mandatory installation of terrain warning systems on

air ambulance aircraft. The NTSB also found that many air ambulance accidents

occur when patients are not on board, such as en route to an accident scene. Present

regulations allow air ambulances to operate under a less stringent set of rules with

regards to weather minimums and pilot duty times when not carrying patients.

However, the NTSB believes that air ambulance flights should operate under more

stringent commercial operating rules at all times that medical personnel are carried

on board. Although maintenance issues have been identified in about 20 percent of

all air ambulance accidents, neither the Federal Aviation Administration (FAA) nor

the NTSB has placed any specific emphasis on oversight of operators or repair

stations that maintain air ambulance aircraft. The present emphasis on air ambulance

safety has, instead, been dominated by concerns over flight crew performance and

weather-related factors.

A variety of options are available to improve safety among air ambulance

operators. These options include intensified oversight of air ambulance operators and

regulatory changes to bring all phases of air ambulance operations under the same set

of operational rules regarding weather minimums and pilot duty times; possible

regulatory changes to provide for sharing and analysis of safety-related data and

observations with some degree of impunity; possible aircraft design considerations

to improve crash survivability; expanded application of system safety and formal

risk management principles to mission planning and flight operations; enhanced

training for both pilots and support personnel and operational procedures to improve

coordination and situation awareness among the entire air ambulance crew and

ground support team; and the use of various technologies to improve pilot situation

awareness and augment pilot vision in low visibility conditions.

This report will not be updated.

Contents

An Analysis of Air Ambulance Safety Data . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1

The Role of Air Ambulances . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5

State of the Air Ambulance Industry . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7

Causes of Air Ambulance Crashes . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9

Interaction Between Pilots and Flight Conditions . . . . . . . . . . . . . . . . 10

Pilot Situation Awareness of Weather Conditions . . . . . . . . . . . . . . . 11

Mission Pressures . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11

Conditions in the Flight Environment . . . . . . . . . . . . . . . . . . . . . . . . . 13

Mechanical Failures and Maintenance Related Crashes . . . . . . . . . . . 14

Options for Improving Safety . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14

Regulatory Standards and Oversight . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14

Conducting Special Emphasis Inspections . . . . . . . . . . . . . . . . . . . . . 15

Applying Consistent Regulatory Requirements During All Phases of

Operation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 16

Addressing Concerns Over Pilot Fatigue . . . . . . . . . . . . . . . . . . . . . . . 16

Increasing Maintenance Oversight . . . . . . . . . . . . . . . . . . . . . . . . . . . . 18

Improving Aircraft Crashworthiness . . . . . . . . . . . . . . . . . . . . . . . . . . 18

Implementing System Safety and Risk Management Principles . . . . . . . . . 19

Training and Procedures for Flight and Medical Crews . . . . . . . . . . . . . . . 20

Technology to Improve Safety in Low Visibility Conditions . . . . . . . . . . 22

Terrain Warning Systems . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 23

Technologies to Enhance In-Flight Visibility . . . . . . . . . . . . . . . . . . . 23

List of Figures

Figure 1. Three-Year Moving Average of Estimated Overall and Fatal Accident

Rates for Helicopter Air Ambulance Operations . . . . . . . . . . . . . . . . . . . . . . 3

Figure 2. Factors in Helicopter Air Ambulance Accidents

(1991 -2004) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10

The Safety of Air Ambulances

Air ambulances that conduct emergency medical service operations and other

medical-related transport services include both helicopter emergency medical

services (HEMS) that primarily conduct scene response transport of trauma patients

and fixed-wing aircraft operations that primarily conduct inter-facility transports of

critical care patients. The air ambulance industry has grown significantly over the

past 25 years and is widely regarded as having a beneficial effect on improving the

chances of survival and recovery for trauma victims and other critical patients,

especially in rural areas. However, during this time, the air ambulance industry has

been the focus of two in-depth National Transporation Safety Board (NTSB) special

safety studies and numerous other investigations by aviation safety researchers that

have pointed to continued concerns over the safety of its flight operations,

particularly among helicopter air ambulance operators. Although the air ambulance

industry and Federal Aviation Administration (FAA) regulators have taken some

positive steps to address continued concerns over operational safety, the NTSB and

some other aviation safety experts have voiced concerns that not enough has been

done to reduce the risk of accidents in air ambulance operations.

This report analyzes available air ambulance safety data, examines the current

state of the air ambulance industry and factors that may influence safety within the

industry, assesses causal factors underlying the recent spate of air ambulance crashes,

and discusses some available options for improving safety.

An Analysis of Air Ambulance Safety Data

A recent increase in the number of crashes involving air ambulances has raised

concerns among aviation safety experts. According to a National Transportation

Safety Board (NTSB) special study focusing on aviation emergency medical

operations released in January 2006, 55 crashes involving air ambulances occurred

in the United States between January 2002 and January 2005.1 The NTSB noted that

this number of crashes has not been seen since the 1980s. Given that the current air

ambulance fleet is estimated to consist of about 750 helicopters and 150 fixed wing

aircraft,2 each year over the past three years, about one in every 50 helicopter air

ambulances has been involved in a crash. An article in USA Today offered the

following stark analogy: “If commercial airlines lost the same proportion of large

1

National Transportation Safety Board, Special Investigation Report on Emergency Medical

Service Operations. NTSB/SIR-06/01.

2

Foundation for Air-Medical Research & Education (FARE), Air Medicine: Accessing the

Future of Health Care, Alexandria, VA: FARE, 2006.

CRS-2

passenger jets as air ambulance companies lost helicopters, 90 airliners would crash

each year.”3

Because there is no centralized database of flight records for the air ambulance

industry, no one knows for sure if safety is eroding or if this increase in accidents can

be explained by the large growth in the use of helicopters and airplanes for medical

evacuation and patient transport. The NTSB notes that while industry estimates

suggest that the number of hours flown by air ambulances has increased by about

85% over the past 15 years, the estimated accident rate for helicopter air ambulances

has also risen from 3.52 accidents per 100,000 flight hours between 1992 and 2001

to 4.56 accidents per 100,000 flight hours between 1997 and 2001.4 The NTSB,

however, did not provide its own estimates of accident rates or more recent figures

on the annual accident rates for air ambulances.

Available accident statistics and analyses reviewed by CRS have focused on

helicopter air ambulance operations, which make up more than 80% of the air

ambulance fleet. Consequently this report concentrates on safety data and finding

related to helicopter air ambulances, although many of the issues and observations

may be more broadly applicable to both helicopter and fixed-wing air ambulances.

While much of the flight hour data to substantiate accident rate statistics for air

ambulance operations remains sketchy, CRS analyzed helicopter air ambulance

safety data and computed accident rates using accidents between 1991 and 2004

identified in the 2006 NTSB special study report, and accident data and industry

estimates of hours flown by helicopter air ambulance operators cited in a

comprehensive safety review and risk analysis of air ambulance accidents published

by the Air Medical Physician Association (AMPA).5 This analysis estimated that the

overall accident rate among air ambulance operators from 1991 to 2004 to be 3.50

accidents per 100,000 flight hours and the fatal accident rate to be 1.13 accidents per

100,000 flight hours. Looking only at the data since 1998 when a notable spike in

accidents was first observed, the estimated overall accident rate rose to an average

of 4.75 accidents per 100,000 flight hours and the estimated fatal accident rate

increased slightly to 1.25 accidents per 100,000 flight hours. Three-year moving

averages of the estimated accident rate were computed across the 14 year period

3

Alan Levin and Robert Davis, “Surge in Crashes Scars Air Ambulance Industry.” USA

Today, July 18, 2005, A1.

4

Ibid. See also Ira J. Blumen, M.D., and the University of Chicago Aeromedical Safety

Committee, A Safety Review and Risk Assessment in Air Medical Transport, 2002, Air

Medical Physicians Association, Salt Lake City, UT.

5

CRS analysis of annual accident data and flight hour estimates provided in National

Transportation Safety Board, Special Investigation Report on Emergency Medical Service

Operations and Ira J. Blumen, M.D., and the University of Chicago Aeromedical Network.

A Safety Review and Risk Assessment in Air Medical Transport, 2002. Note: for 2002

through 2004, CRS interpolated estimated flight hours based on industry flight hour

estimates provided for previous years and an estimate of 300,000 hours flown in 2005 cited

in the NTSB report. This yielded an average annual increase in flight hours between 2001

and 2004 of roughly 9.3%.

CRS-3

based on available flight time estimates and are shown in Figure 1.6 The trend in the

three-year moving average accident rates suggests a steady increase in the accident

rate from 1991 through 2003, with a slight reversal of this trend in 2004. The data

also show a slight rise in the fatal accident rate over the past five years. While these

data demonstrate an increase in helicopter air ambulance accident rates, particularly

since 1998, they cannot be regarded as conclusive because of the lack of reliable data

on the overall number of hours flown. However, these data, based on best available

information, strongly suggest that there is cause for concern regarding the safety

trend for air ambulance operations.

Accident Rate (Per 100,000

Flight Hours)

Figure 1. Three-Year Moving Average of Estimated Overall and Fatal

Accident Rates for Helicopter Air Ambulance Operations

6

5

4

3

2

1

0

1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004

Year

All Accidents

Fatal Accidents

Sources: CRS analysis of annual accident data and flight hour estimates provided

in National Transportation Safety Board, Special Investigation Report on

Emergency Medical Service Operations. NTSB/SIR-06/01 and Ira J. Blumen,

M.D., and the University of Chicago Aeromedical Network. A Safety Review and

Risk Assessment in Air Medical Transport, 2002, Air Medical Physicians

Association, Salt Lake City, UT. Note: A three-year moving average computes

the accident rate using the data from the current year and the two prior-years.

There are two key concerns regarding these accident rate estimates. First, the

trend shows a steady increase in estimated accident rates over the past 14 years, with

6

A three-year moving average, sometimes referred to as a three-year rolling average, is an

accident rate calculation based on accidents and flight hours during the referenced year and

the two prior years. So, for example, the data points for 1993 are based on accidents and

flight hour estimates for 1991, 1992, and 1993. This is done to provide a more stable metric

for analyzing trends among accident rates that may fluctuate significantly from year to year.

CRS-4

a more marked increased since 1998. Second, these estimated accident rates are

notably higher than many other commercial aviation sectors. In particular, over the

same period (from 1991-2005), non-scheduled air taxi operators, which fly under the

same rules as air ambulance operators carrying patients, experienced an overall

accident rate of 2.52 accidents per 100,000 flight hours and a fatal accident rate of

0.67 fatal accidents per 100,000 flight hours.7 While air ambulance operations,

particularly helicopter air ambulance operations, by their nature may arguably be

inherently more risky than other commercial aviation operations, the relatively higher

estimated accident rates coupled with the observed trend of increasing accidents and

estimated accident rates suggests that the causes of these accidents and possible

options to reduce these numbers is an appropriate topic for policy analysis.

When the NTSB previously examined commercial emergency medical service

helicopter operations in 1988, it estimated that the overall accident rate between 1980

and 1985 was 12.34 per 100,000 flight hours, almost twice the estimated accident

rate experienced by non-scheduled helicopter air taxis during that period.8 Moreover,

the fatal accident rate of 5.40 per 100,000 flight hour for helicopter air ambulances

between 1980 and 1985 was estimated to be about 3 ½ times the fatal accident rate

for non-scheduled helicopter air taxis and all turbine-powered helicopters.9 While

more recent accident rate estimates among helicopter air ambulance operators have

been climbing steadily, they still appear to be much lower than estimates for the early

1980s. However, the lower observed accident rates in the early 1990s suggest that

safety improvements can be made in air ambulance operations to reduce the overall

and fatal accident rates compared to recently observed levels. Specifically, between

1991 and 1995, the helicopter air ambulance industry had an estimated 1.81 accidents

and 0.91 fatal accidents for every 100,000 flight hours, accident rates that closely

resemble those of other commercial aviation operations such as the previously cited

statistics for non-scheduled air taxi operators. Arguably, based on these data, the

helicopter air ambulance industry has already demonstrated that it can achieve a

better safety record than what it has experienced since 1998.

Although air ambulance operations can be inherently riskier than other aviation

operations because the environment in which they operate is more dynamic and

unpredictable, some experts have raised concerns that the air ambulance industry and

the FAA are simply accepting a higher accident rate than other areas of the aviation

industry rather than taking steps to reduce the number of accidents.10 While the FAA

and the air ambulance industry have acknowledged that ongoing safety concerns

7

Both non-scheduled air taxi operators and air ambulance operations with patients on board

are conducted under Title 14 Code of Federal Regulations, Part 135. CRS calculations

based on data provided in: National Transportation Safety Board, Accidents, Fatalities, and

Rates, 1986 - 2005, 14 CFR Part 135, Nonscheduled Service (On-demand Air Taxis).

8

Non-scheduled helicopter air taxi are operated under Title 14 Code of Federal Regulations,

Part 135 and generally do no include local air tours that are exempt from operating under

this set of regulations.

9

National Transportation Safety Board, Commercial Emergency Medical Service Helicopter

Operations, NTSB/SS-88/01.

10

Alan Levin and Robert Davis, “Surge in Crashes Scars Air Ambulance Industry.”

CRS-5

exist, critics argue that their actions to date — largely consisting of advisory

materials and recommendations requiring only voluntary compliance by operators —

are inadequate. To further assess the root causes of air ambulance accidents and

assess possible policy changes to improve safety in the air ambulance industry, it may

be beneficial to examine the operational role of air ambulances as well as the current

state of the air ambulance industry and management practices in the air ambulance

industry.

The Role of Air Ambulances

When most people think of an air ambulance operation they are likely to first

consider helicopter transports of trauma patients, such as car accident victims. This

has historically been the predominant form of air ambulance service since its

beginnings in the early 1970s. Large scale use of air evacuation of wounded troops

was demonstrated to be an effective means of reducing combat mortality both in the

Korean and Vietnam conflicts. Based on this experience, civilian air ambulance use

in the United States began on a small scale starting in the early 1970s and has grown

significantly since. Although some studies have found little or no benefit from

helicopter evacuations of civilian trauma patients, numerous studies point to

improved chances for recovery and significant reductions in mortality rates when air

ambulance services are made available to trauma patients.11 Medical theory and

practice holds that providing critically injured patients with surgical intervention

within the first hour after injury – the so-called “Golden Hour” – can significantly

improve the chances for survival and recovery.12 In practice, air ambulances,

particularly helicopters, can play an important role in this intervention by providing

rapid patient transport to trauma centers where they can be effectively treated, and

in some cases providing advanced life support capabilities en route. The availability

of this service provides an important role, especially in rural communities that lack

readily accessible advanced care facilities and medical specialists.

More recently, there has been increased utilization of air ambulances, both

helicopters and airplanes, for both on-scene response and inter-facility transport of

critical cardiac patients and stroke victims. Both helicopters and fixed-wing aircraft

are also utilized for other inter-facility transfers to give patients access to specialty

care facilities and medical specialists. While the on-scene response of a helicopter

at a traffic accident is probably what first comes to mind when the term air

ambulance is used, today about 54% of all air medical transports are from hospital

to hospital, while on-scene responses make up 33%. The remaining 13% include

organ and medical supply and speciality medical team transports.13 Air ambulances

can also play an important role in emergency evacuation of critical care patients and

11

Association of Air Medical Services (AAMS), AAMS Brief – Part 3: Air Medical

Research and What It Shows. Alexandria, VA: AAMS; National Transporation Safety

Board, Commercial Emergency Medical Service Helicopter Operations; Foundation for AirMedical Research & Education (FARE), Air Medicine: Accessing the Future of Health

Care.

12

Foundation for Air-Medical Research & Education (FARE), Air Medicine.

13

Ibid.

CRS-6

transport of medical supplies and staff to disaster areas, as was demonstrated in the

aftermaths of Hurricanes Katrina and Rita in 2005.14

While some critics assert that air ambulance transports are being over utilized,15

there is generally widespread acceptance of the benefit provided by both the general

public and the medical community. The air ambulance community acknowledges

that utilization of air ambulances in some cases may, in retrospect, prove to have

been unnecessary. This, they argue, is to be expected if the medical community is

to assure that the maximum number of patients who could potentially benefit from

air ambulance services are provided with this service. Over the past 15 years,

guidelines for air medical dispatch have been refined by the air ambulance

community and emergency room physicians. These various guidelines set forth

circumstance-specific and patient-specific criteria for decision makers assessing

whether to dispatch a flight as well as for analysts reviewing and modeling utilization

and refining resource allocation across a particular geographic area.16 The industry

also argues that while air ambulance services are comparatively costly when

examined on a single-case basis, appropriately used air medical transport is costeffective on a system-wide basis, largely due to more efficient coverage of large

geographic areas, reduced patient transport times, and more rapid intervention that

can reduce overall patient care costs.17 In general, air ambulance services have

garnered wide community support and endorsement from the medical community as

being a beneficial and cost-effective service for improving access to critical health

care and increasing the chances of survival and recovery for trauma victims and

critically ill patients, particularly in areas where access to specialized health care is

limited. Consequently, air ambulance utilization is likely to continue its steady

growth throughout the United States, particularly in rural areas. This expectation of

continued growth for the industry draws particular attention to the ongoing safety

concerns, because continued growth without any improvement to safety could trigger

widespread public concern over the safety of these operations which has already been

evidenced to some degree based on recent media coverage of the issue.18

State of the Air Ambulance Industry

The civilian air ambulance industry can trace its origins back to the early 1970s

with the creation of the Maryland State Police aviation program in 1970 and the first

hospital-based medical helicopter service at St. Anthony’s Hospital in Denver,

Colorado in 1972. Prior to then, police departments in the 1960s and early 1970s had

14

Ibid. Note: Unlike other helicopters and aircraft used in search and rescue (SAR) and

relief missions during natural disasters, dedicated air ambulances are specially equipped and

staffed for transporting sick and injured patients. This report only discusses safety data and

issues for dedicated air ambulance aircraft.

15

Barry Meier. “Crashes Start Debate on Safety of Sky Ambulances.” The New York

Times, February 28, 2005.

16

Foundation for Air-Medical Research & Education (FARE), Air Medicine.

17

Ibid.

18

See especially Barry Meier. “Crashes Start Debate on Safety of Sky Ambulances” and

Alan Levin and Robert Davis, “Surge in Crashes Scars Air Ambulance Industry.”

CRS-7

used helicopters on occasion to transport critical patients, but provided very limited

en route patient care. The air ambulance industry gradually grew during the 1970s

and by 1980 included 32 helicopter emergency services flying 39 helicopters. During

the 1980s, the industry grew fivefold and by 1990 included 174 helicopter emergency

services and 231 helicopters. The industry experienced continued growth in the

1990s expanding to 231 helicopter emergency services flying 400 helicopters by

2000.19

A variety of factors, including increases in Medicare reimbursement rates for air

ambulance services and recent declines in available emergency medical and advanced

patient care services in rural areas, have resulted in a significant growth in the air

ambulance industry over the past five years. In 2005, there were 272 helicopter

emergency services flying 753 helicopters in the United States, roughly an 88%

increase in the number of helicopter air ambulances compared to the size of the

industry in 2000. In 2005, there were also an estimated 150 fixed-wing airplanes

dedicated to air ambulance operations used mostly for inter-hospital transfers.20

Based on industry flight hour estimates, growth in the use of air ambulances has been

increasing at a rate of about 4.5% per year over the past 15 years, and most observers

believe that this steady growth in both the size of the dedicated air ambulance fleet

in the United States and the utilization of air ambulances will continue over the next

several years.

While some states and municipalities and other public agencies operate air

ambulances as public aircraft, most air ambulance services are privately owned and

operated, either directly by a hospital or hospital consortium or by private aviation

medical service providers. The Maryland State Highway Patrol has a comprehensive

helicopter air ambulance capability that covers the entire state, while the California

Highway Patrol and the Virginia and Delaware State Police provide air ambulance

services in portions of those states. Several county police forces and emergency

medical units throughout the United States also perform air ambulance missions.

Also, federally operated aircraft provided by the U.S. Coast Guard in Alaska and the

U.S. Army in Hawaii conduct civilian air ambulance operations. CRS estimates that

federal, state, and local government-operated aircraft currently account for about 10%

of air ambulance operations in the United States. However, private operators make

up the large majority of air ambulance services across the United States.21 Unlike

aircraft that are operated by a state or local agency which are considered public

aircraft and therefore not under direct FAA oversight, air ambulances operated by

private companies are regulated by the FAA, and therefore have been the focus of

safety studies examining safety within the industry and the FAA’s actions to monitor

and regulate safety.22 These private aviation medical providers may operate under

19

Foundation for Air-Medical Research & Education (FARE), Air Medicine.

20

Ibid.

21

See the Association of Air Medical Services (AAMS), Atlas & Database of Air Medical

Services (ADAMS). AAMS National Office, Alexandria, VA for a comprehensive

geographic database of air ambulance service coverage across the United States.

22

CRS is not aware of any study examining the safety of public aircraft used as air

(continued...)

CRS-8

direct contract providing aircraft and flight crews to a specific hospital or hospital

consortium, or as is becomingly increasingly more common, may act more as a

independent entity with affiliations with various hospitals over a large geographic

region.

In the late 1990s, regulatory changes requiring ambulance services, including

air ambulances, to bill patients separately from hospital charges as well as increases

in Medicare reimbursement for air ambulance flights in some regions, brought about

significant changes to the industry.23 Most helicopter emergency medical services

in the 1980s and early 1990s were either run directly by hospitals and emergency

facilities or, more commonly, operated under hospital-managed contracts with

aviation companies that provided the helicopters and pilots.24 Today, many of these

services are now operated by stand-alone, private entities with hospital affiliations,

and in many locations, there is direct competition between air ambulance service

providers within a region.

While some states and local governments provide air ambulance services as a

public good or quasi-public good, privately-run operations are far more common.

The Maryland State Police Aviation Command, as an example of a state-run system,

derives about two-thirds of its funding from automobile registration fees and the

remainder from general state treasury funding for the state police. Patients are

consequently not required to pay for transport and medical costs provided by this

service. In the privately-operated air ambulance model, by contrast, patients or their

insurers are directly billed for charges incurred for air ambulance transport. Although

privately-operated air ambulance services provide an important function in the

communities they serve, critics argue that the financial pressures associated with

operating these services as well as insufficient regulatory requirements and oversight

may be significant factors that could negatively affect flight safety across the

industry.

Although competition and associated pressures to conduct missions was already

present when the NTSB examined air ambulance helicopter safety in 1988, it was

generally concluded that helicopter patient transport at that time was not profitable

on the basis of transportation alone. In fact, a 1986 survey cited by the NTSB found

that patients were, on average, only charged for about 75% of the direct cost of air

ambulance transport.25 Hospitals made up for these losses through charges for other

advanced care services provided at the hospital. Thus, the competition that existed

22

(...continued)

ambulances or any study comparing safety between private air ambulance operators and

those operated by state and local government entities.

23

Barry Meier, “Crashes Start Debate on Safety of Sky Ambulances.” The New York Times,

February 28, 2005. Also see, Title 42 Code of Federal Regulations, Part 414, Subpart H:

Fee Schedule for Ambulance Services.

24

Ibid. See also, National Transportation Safety Board, Safety Study: Commercial

Emergency Medical Service Helicopter Operations.

25

National Transportation Safety Board, Safety Study: Commercial Emergency Medical

Service Helicopter Operations.

CRS-9

in the 1980s was largely between hospitals. From a business perspective, air

ambulances, at that time, were largely seen as a marketing tool to increase public

recognition of the hospital within the community and attract patients. In the current

environment, however, the competition appears to be more directly related to the

flight mission as the business model for most private-sector air ambulance services

has been shifting toward stand-alone operators that market their services to local

hospitals, emergency officials, and even to the general public.26 One example of

marketing to the general public is the sales of yearly “memberships” that will cover

any gaps not paid by insurance for air ambulance transports.27 Various competitive

pressures, including direct competition among services and the desire to satisfy

hospital and emergency medical service administrators that oversee air ambulance

contracts, can potentially affect flight safety if they factor into decisions regarding

whether to accept or continue a flight mission. Operating air ambulances as private

businesses may also create financial pressures that could lead some operators to

forego safety improvements or enhancements that are not specifically required in

order to keep operational costs at a minimum. These various operational pressures

that exist in the air ambulance industry and their potential impact on safety will be

considered in greater detail along with other possible causal and contributing factors

in air ambulance crashes.

Causes of Air Ambulance Crashes

The large majority of air ambulance accidents occur due to a chain of

circumstances involving pilot decision-making and performance and flight

conditions such as weather and terrain. In particular, darkness, reduced visibility, and

rising terrain present significant challenges and risks to air ambulance operators –

particularly helicopter operators – and are often cited as causal factors in accidents.

Pilot knowledge or “situation awareness” regarding weather conditions and terrain

has also been found to be a significant factor in a large number of air ambulance

accidents.

CRS analyzed a database of 120 helicopter air ambulance accidents compiled

by the Helicopter Association International that occurred between 1991 and 2004.

Causal factors were categorized based on brief descriptions of the accident

circumstances and weather conditions provided in this database. The results of this

analysis are shown in Figure 2.

26

Barry Meier, “Crashes Start Debate on Safety of Sky Ambulances.”

27

Ibid.

CRS-10

Figure 2. Factors in Helicopter Air Ambulance Accidents

(1991 -2004)

22.5

Mechanical

Aircraft / Systems

Obstructions

4.2

5.0

Mountain

Weather/ Visibility

Flight Environment

9.2

Night

14.2

CFIT

27.5

ADM/SA

27.5

9.2

VFR into IMC

Fuel Management

1.7

Operator / Pilot

Pilot Technique

13.3

LOC

8.3

Visual Illusions

1.7

0.0

5.0

10.0

15.0

20.0

25.0

30.0

Percent of Accidents

Source: CRS analysis of accident synopses provided in Helicopter Association

International, Air Medical Service Accidents, 1991 thru 1994, Alexandria, VA.

Note: CFIT: Controlled Flight into Terrain; ADM: Aeronautical Decision

Making; SA: Situation Awareness; VFR into IMC: Visual Flight Rules into

Instrument Meteorological Conditions. Percentages sum to more than 100%

because many accidents were assigned to more than one causal factor.

Interaction Between Pilots and Flight Conditions. The interplay

between the pilot or flight crew (the operator) and environmental factors such as

weather and terrain played a part in roughly 80% of the accidents examined. This

finding closely matches other analyses examining the causes of air ambulance

crashes.28 One of the most common causal factors in these accidents, cited in 27.5%

of the crashes, was what aviation safety experts refer to as controlled flight into

terrain (CFIT), a broad category that generally involves a loss of situation awareness

regarding surrounding terrain, often in poor visibility or at night. The other most

cited factor, also identified in 27.5% of the accidents, was aeronautical decision

making and situation awareness (ADM/SA), which refers to a pilot’s knowledge of

factors affecting the safety of flight and the ability to evaluate risk based on these

factors and make appropriate informed decisions. Another contributor to helicopter

air ambulance crashes, related to errant pilot decision making, is continuing a flight

using outside visual references as is permissible under visual flight rules (VFR) into

28

See Ira J Blumen, M.D., and the University of Chicago Aeromedical Safety Committee,

A Safety Review and Risk Assessment in Air Medical Transport.

CRS-11

poor weather and visibility conditions, known to aviators as instrument

meteorological conditions (IMC). Continued VFR into IMC, as it is referred to by

air safety experts, was cited as a causal factor in 9% of helicopter air ambulance

crashes. Other pilot-related factors cited in a number of accidents included loss of

aircraft control, pilot technique, and visual illusions, all factors that frequently crop

up in poor visibility conditions when a pilot loses visual reference to the horizon or

the ground below and is unable to effectively transition to flight solely by reference

to cockpit instruments. These flight operational factors are a central concern and

have been the focus of the NTSB’s safety recommendations regarding air ambulance

operations as well as the efforts of the FAA and the air ambulance industry to

encourage voluntary implementation of systems safety and risk management concepts

in air ambulance operations.

Pilot Situation Awareness of Weather Conditions. In its most recent

review of air ambulance safety, the NTSB found that situation awareness can often

be lacking in air ambulance operations for a variety of reasons, but was chiefly

concerned with the lack of formal flight dispatch procedures among operators. Air

ambulance pilots lack the benefit of consistent, comprehensive flight dispatch

procedures and often rely on emergency (911) dispatchers, referred to in the industry

as communications specialists, or emergency medical personnel that typically have

no formal training in flight dispatch procedures. In 11 of the 55 accidents reviewed

by the NTSB in their 2006 special study, incomplete or missing information

regarding weather, route of flight, and coordination with on-scene rescue personnel

factored into the causal chain of the accident. The NTSB, consequently,

recommended that the FAA require air ambulance operators to use formalized

dispatch and flight-following procedures that include up-to-date weather information

and assistance in flight risk assessment decisions.29 In response to this

recommendation, policymakers might opt to assess the benefits and costs of

implementing formal flight dispatch procedures and specific training in these

procedures to both flight crews and ground communication specialists in the

emergency medical field that coordinate and dispatch air ambulance missions.

Mission Pressures. Aviation safety experts have also pointed to pressures

to complete the mission as factors that can lead to poor judgment among air

ambulance pilots and contribute to accidents. In 1988, the NTSB found that mission

pressures could be exacerbated by a lack of on-site supervision among operators,

particularly those operators that service a broad geographic area. In many of these

instances, the NTSB found that a pilot’s immediate supervisor was not located at the

pilot’s base station or hospital, and in some cases, was located in a distant city. The

NTSB concluded that isolation from management forces pilots to look for structure

and guidance from other sources, particularly hospital emergency service

administrators and personnel. This arrangement can result in pilots placing greater

importance on the medical mission and potentially may compromise sound judgment

with regard to flight safety. The NTSB noted that:

29

National Transportation Safety Board, Special Investigation Report on Emergency

Medical Service Operations.

CRS-12

[h]ospital management, the EMS medical personnel, and the dispatchers can all

intentionally or unintentionally put pressure on the pilots to take a flight in

marginal weather conditions. The reasons for these pressures include

misunderstanding or lack of understanding of weather-related considerations,

genuine zeal to get a job done, or even competition between EMS programs.30

The NTSB also found that, besides the pressures to complete missions based on

medical need influencing flight safety considerations, the relationship between air

ambulance operators and hospitals can play a role in decisions regarding whether to

accept or continue a mission. Pilots may feel pressured to accept or continue

missions in marginal weather conditions in order to satisfy hospital administrators

and maintain good business relations with them. In privately-operated air ambulance

services, the hospital is, in essence, a customer of the air ambulance service, and

pilots may feel compelled to satisfy their customer by accepting and completing a

maximum number of missions. These pressures may be even greater at hospitals and

in regions where there is direct competition among air ambulance providers.

A survey of helicopter air ambulance pilots found that while pressure to accept

or continue missions is a significant concern, pilots more frequently cited pressure

to speed up response time as the most significant pressure factor affecting mission

safety. Internal and external pressures to speed up response time could cause pilots

to miss important risk factors and fail to obtain a full understanding of the weather,

route of flight, obstacles and obstructions en route, and other key pieces of

information during the flight preparation process.

Policymakers may consider options to require specific training and

implementation of risk management techniques for air ambulance operators dealing

with the specific operational environment and operational pressures of the air

ambulance industry. While the FAA has provided a variety of training materials and

resources on aeronautical decision making that are both general in nature as well as

specific to unique considerations for helicopter and air ambulance operations,

decision making and various external pressures that may effect pilot judgment on air

ambulance missions is often not covered in depth during initial and recurrent pilot

training. Therefore, policymakers may consider more formal training and testing of

aeronautical decision making concepts specific to air ambulance operations as a

possible option for mitigating accidents related to poor judgment and decision

making errors.

Besides training in aeronautical decision making, formal techniques for

evaluating the operational risks associated with each flight assignment may benefit

pilots in the decision making process. The FAA has recommended that helicopter

air ambulance operators implement formal operational risk assessment programs to

evaluate flight safety and risk for every mission.31 The recommended practices

include empowering pilots to be the final decision authority in accepting or declining

30

National Transportation Safety Board, Commercial Emergency Medical Service

Helicopter Operations, p. 17.

31

Federal Aviation Administration. FAA Notice N8000.301: Operational Risk Assessment

Programs for Helicopter Emergency Medical Services. August 1, 2005.

CRS-13

a mission assignment; incorporating formal risk assessment tools for gauging the

level of risk on a specific mission; and carrying out a risk mitigation plan to reduce

risks to acceptable levels when feasible. Factors considered in formal pre-flight risk

assessments include weather and visibility conditions; terrain and route of flight;

pilot qualifications, experience ,and fitness for duty; any maintenance issues such as

inoperative equipment; and aircraft performance capabilities and limitations.

Examples of techniques for mitigating risk factors may include more stringent

weather minimums for less experienced pilots; more stringent weather minimums

when certain equipment is inoperative or otherwise unavailable; and the use of

special equipment to improve a pilot’s situation awareness and ability to see and

avoid terrain and obstructions at night and in poor visibility. While the FAA has

issued voluntary guidance to helicopter air ambulance operators set up these risk

management programs, the NTSB has recommended that these flight risk evaluation

programs be made mandatory for all air ambulance operators, and require formal

training in the risk evaluation process for all employees directly involved in flight

missions, not just pilots.32

Conditions in the Flight Environment. With regard to environmental

conditions, night, weather, obstructions (such as power-lines) and mountainous

terrain, or some combination of these factors was found to have played a role in a

large number of the helicopter air ambulance accidents reviewed by CRS. Presently,

air ambulance operators, for the most part, are not required to equip their aircraft with

instruments that could improve situation awareness regarding height above terrain

and potential terrain collisions, nor are they required to utilize any special equipment

that could enhance visibility at night and in poor weather conditions. While the

FAA, in its guidance to air ambulance operators and inspectors who oversee these

operations issued in January, 2006, identified this equipment as a means to avoid loss

of control and CFIT accidents, it has not required use of this equipment to date.33

However, the NTSB issued a recommendation to the FAA, based on its 2006 special

study findings, that would specifically require the use of terrain warning systems on

air ambulances.34

Mechanical Failures and Maintenance Related Crashes. In addition

to flight operational factors and conditions of flight, a significant proportion (about

22%) of the helicopter air ambulance accidents examined were found to be

attributable, at least in part, to some type of mechanical failure. This finding roughly

matches that of an earlier comprehensive study looking specifically at maintenancerelated helicopter air ambulance accidents over a 24-year period which concluded

that 23% of all helicopter air ambulance accidents reviewed were maintenance-

32

National Transportation Safety Board, Special Investigation Report on Emergency

Medical Service Operations

33

Federal Aviation Administration. Helicopter Emergency Medical Services (HEMS) Loss

of Control (LOC) and Controlled Flight Into Terrain (CFIT) Accident Avoidance Programs,

Flight Standards Handbook Bulletin for Air Transportation (HBAT) 06-02A, January 23,

2006.

34

National Transportation Safety Board, Special Investigation Report on Emergency

Medical Service Operations.

CRS-14

related.35 That study found that 50% of helicopter air ambulance crashes attributable

to mechanical or maintenance-related causes were engine related, while 24% were

due to failures of the main rotor drive or transmission, 13% were attributed to

malfunctions of the tail rotor system, and another 13% were attributed to faulty flight

controls. These findings suggest that maintenance of air ambulances poses a

significant safety risk. However, neither the FAA nor the NTSB has identified

maintenance practices among air ambulance aircraft as a specific area for concern.

Consequently, present efforts to prevent air ambulance crashes are focused, instead,

on risk factors associated with flight operations and pilot performance. Available

data suggests that policymakers might also choose to consider a more in-depth

examination of maintenance practices in the air ambulance industry to identify ways

to reduce maintenance-related accidents.

Options for Improving Safety

Based on available data summarized above suggesting that flight operational

factors are the central cause of the large majority of air ambulance accidents, options

for improving safety have focused on possible changes to flight operations and

practices among air ambulance operators. These various options have been framed

in terms of possible alternatives for changing regulatory standards and oversight of

air ambulance operators, incorporating system safety and risk management principles

into the decision making processes regarding air ambulance missions, providing

additional or supplemental training for flight crews as well as medical crews, and

incorporating various technologies to aid pilots and improve safety in low visibility

conditions.

Regulatory Standards and Oversight

Media coverage of air ambulance safety has raised concerns over the degree of

oversight that the FAA has devoted to air ambulance operators, asserting that the

FAA has been unable to keep pace with the industry’s rapid growth.36 Those

expressing concern believe that the FAA has been lax in inspecting air ambulance

operations, particularly for new operators and operational bases, as well as at remote

base stations that are distant from company headquarters.37 In terms of regulations,

critics also contend that the FAA has been slow to take action to better regulate safety

among air ambulance operators. The NTSB noted that while the FAA has taken a

positive step toward improving air ambulance safety by creating a task force in

August 2004 to look into helicopter air ambulance accidents, that task force had not

yet made any specific recommendations or proposals for regulatory change.38 The

FAA has, however, issued special guidance to helicopter air ambulance operators and

has intensified efforts to review these operators’ training and procedures.

35

Ira J. Blumen, M.D., and the University of Chicago Aeromedical Safety Committee, A

Safety Review and Risk Assessment in Air Medical Transport, 2002.

36

Alan Levin and Robert Davis, “Surge in Crashes Scars Air Ambulance Industry.”

37

Ibid.

38

National Transportation Safety Board, Special Investigation Report on Emergency

Medical Service Operations.

CRS-15

Conducting Special Emphasis Inspections. In Fall 2005, the FAA

initiated a special emphasis inspection program targeting helicopter air ambulance

operators. The inspection program is designed to focus on policies, procedures,

training, communications, and management of flight operations and the development

of safety culture among operators with the goal of identifying and correcting factors

known to contribute to accidents among helicopter air ambulances.39 The FAA has

also issued a special bulletin for developing and critiquing air ambulance operator

training programs and operating procedures that are specifically designed to prevent

loss of control and CFIT accidents.40 FAA inspectors will be looking for specific

improvements to pilot training to deal with inadvertent flight into low visibility

conditions, flight solely by reference to cockpit instruments, and recovery from

unusual aircraft attitudes.41 Inspectors will also be looking at air ambulance operators

to see if they have implemented various procedures, such as pre-flight assessments

of obstacles and terrain considerations along the route of flight, and the use of

approved technologies to aid in-flight situation awareness in an effort to curtail

accidents.

Applying Consistent Regulatory Requirements During All Phases

of Operation. The NTSB also noted that when patients are not on board, for

example during positioning flights or en route to an accident scene, air ambulance

operators may operate under a less stringent set of regulations, because the FAA

regards medical personnel on board as essential crew members.42 When operating

under these less stringent regulations, air ambulance operators have no set minimum

requirements for in-flight visibility nor do any regulations pertaining to flight and

duty time for pilots apply. The NTSB found that, of the 55 air ambulance accidents

studied, 35 occurred while operating under these less stringent regulations without

patients on board. In 10 of these accidents, the flights were being conducted in

weather conditions that would not have met the minimum requirements for operation

under the more stringent set of commercial regulations required for flights with

patients on board. The NTSB concluded that, in its opinion, medical personnel on

39

Federal Aviation Administration. Notice N8000.307: Special Emphasis Inspection

Program for Helicopter Emergency Medical Services. September 27, 2005.

40

Federal Aviation Administration. Flight Standards Handbook Bulletin for Air

Transportation (HBAT) 06-02A: Helicopter Emergency Medical Services (HEMS) Loos of

Control (LOC) and Controlled Flight Into Terrain (CFIT) Accident Avoidance Programs.

Effective 1/23/2006, Revised 3/14/2006.

41

Aircraft attitude refers to its orientation relative to the horizon. Examples of unusual

attitudes include a steep bank, a dive, a steep climb, or some combination of these

conditions.

42

National Transportation Safety Board, Special Investigation Report on Emergency

Medical Service Operations. Note: Currently flights without patients may be operated under

regulations prescribed in Title 14 Code of Federal Regulations (CFR), Part 91, whereas

flights with patients on board must be operated under regulations contained in Title 14, CFR

Part 135. For the purposes of this discussion, the principal differences between these two

sets of regulations are that under Part 91, there are no flight and duty time limitations and

there are less stringent requirements regarding weather conditions that operators are

permitted to fly in.

CRS-16

board do not meet the definition of required crew members for flight operational

purposes, and therefore recommended that the FAA require air ambulance operators

to comply with more stringent commercial flight regulations whenever medical

personnel are on board, as they currently do when carrying patients.

The fact that air ambulance operations without patients are conducted under

separate regulatory guidelines also has a potential impact on those operations

conducted with patients on board. This is because without any specific duty time

regulations being applied to flights conducted without patients, such flights are not

counted in a pilot’s duty time totals. Therefore, lengthy flight operations without

patients on board could contribute to pilot fatigue and affect safety during subsequent

flights with patients on board. While regulations currently include industry specific

flight time and rest time requirements for helicopter air ambulance pilots,43 flights

flown without patients are not required to be considered in complying with these

regulations. Therefore, notwithstanding the NTSB’s recommendation to conduct all

flights with medical personnel on board as commercial operations subject to specific

duty time limitations, policy makers may consider alternative approaches to account

for and limit pilot duty times in air ambulance operations in a manner that more

accurately reflects actual flight time logged, regardless of whether patients are on

board or not.

Addressing Concerns Over Pilot Fatigue. Addressing the specific issue

of pilot fatigue and duty time regulations among air ambulance operators is regarded

by many aviation safety experts as being very important because the combination of

stress, rotating shift work, and operating at or near the minimal flight crew staffing

levels needed to maintain 24/7 operations is common across the industry and

predisposes pilots to acute and chronic fatigue.44 While fatigue has not been

identified as a causal or contributing factor in very many air ambulance accidents,

this may largely be due to the difficulty in substantiating the presence of fatigue

following an accident. In 1988, the NTSB noted that, while pilot fatigue had only

been identified in one of the accidents it reviewed, pilot fatigue was suggested by

some in the EMS helicopter industry to be the primary cause of accidents.45 Since

that time, because no notable changes have taken place with regard to regulations or

practices pertaining to pilot duty times across the industry, preventing pilot fatigue

would appear to still be a significant objective for improving safety in air ambulance

operations. Therefore, in addition to addressing the broader question of whether air

ambulance flights should adhere to commercial flight regulations during all phases

of a mission, including times when patients are not on board, policymakers may

consider possible changes in pilot duty time and flight time regulations to address

concerns over the potential role of fatigue in the safety of flight operations.

To fully address the issue of pilot fatigue, specific regulations pertaining to

flight time and rest requirements may need to be examined separately from the issue

43

See Title 14, Code of Federal Regulations § 135.271.

44

National Transportation Safety Board, Commercial Emergency Medical Service

Helicopter Operations.

45

Ibid.

CRS-17

of requiring air ambulance operators to conform to other commercial operating

regulations. In particular, those regulations pertaining to weather minimums and

weather reporting requirements, when conducting flights with medical personnel on

board, may need to be examined as a separate issue. Specifically, air ambulance

operators have voiced concerns that applying existing commercial flight regulations

to patient pick-up flights may significantly limit the ability of air ambulances to

accept missions in reduced visibility. This, according to an industry trade group, is

due to the fact that commercial regulations, as currently written, require approved

weather reporting at the intended destination in order to fly solely by reference to

instruments.46 This could significantly limit operators to visual flight conditions

only. Working around this issue may require specific exemptions or a separate set

of requirements for air ambulance operators. Although regulations and policies

pertaining to weather and flight duty time standards for air ambulance operations are

both important issues for consideration, uniformly applying commercial flight

regulations designed primarily for other purposes to all facets of air ambulance

operations may be an imperfect solution. Policy makers may consider tailoring these

regulations to the specific safety concerns and operational needs of the air ambulance

industry by dealing with those regulations pertaining to weather minimums and those

regulations pertaining to pilot duty times as distinct policy issues.

Increasing Maintenance Oversight. As previously mentioned, little

attention has been given to the oversight of maintenance practices at facilities that

maintain and repair air ambulance aircraft. However, consistent with this report’s

findings, an in-depth study of maintenance-related accidents found that about 23%

of helicopter air ambulance accidents may be attributed, in part, to mechanical or

maintenance issues. About one-third of these accidents were regarded as being the

result of inadequate or improper maintenance.47 Given that aviation safety experts

have devoted considerable attention to airline maintenance practices, the lack of any

specific focus on maintenance of air ambulance operations is somewhat surprising,

but this is likely attributable to the fact that these maintenance safety issues are

largely eclipsed by concerns over flight operational safety issues which account for

the large majority of air ambulance crashes. Nevertheless, policymakers may

consider whether additional oversight and scrutiny of air ambulance maintenance

practice may be able to provide additional insight into specific maintenance practices

that compromise safety and available options for preventing maintenance-related

incidents and accidents.

Improving Aircraft Crashworthiness. Aircraft crashworthiness and

accident survivability is another regulatory issue that hasn’t received much attention

with regard to air ambulance safety. A comprehensive examination of helicopter air

ambulance crash injuries and fatalities found that main cabin occupants of air

ambulance helicopters had about 4.5 times the risk of death or serious injury

46

Graham Warwick. “Medical Alert.” Flight International, February 21-27, 2006, pp.

72–73.

47

Based on data presented in Ira J. Blumen, M.D., and the University of Chicago

Aeromedical Safety Committee, A Safety Review and Risk Assessment in Air Medical

Transport, 2002.

CRS-18

compared to occupants of other helicopters.48 The study concluded that the increased

risk is likely attributable to cabin design modifications to accommodate emergency

medical missions. The study went on to identify greater relative risks among lighter

weight air ambulance helicopters (i.e., helicopters weighing less than 4,500 pounds)

in crashes where there was a post-crash fire, among occupants not wearing shoulder

harnesses, and for mechanical-related crashes. For larger helicopters (i.e., helicopters

weighing more than 4,500 pounds), these distinctions between air ambulances and

other helicopters were not as noticeable. This finding could have important

implications if the service model for helicopter air ambulance operations continues

to shift toward more autonomous private operators who may be more likely to use

smaller, lighter-weight helicopters to keep aircraft acquisition and operating costs

low. The study concluded that the use of energy-absorbing seats that can handle

greater crash forces in combination with lap and double-shoulder (five-point)

harnesses, along with greater attention to crashworthiness in designing cabin

modifications for air ambulance operations could significantly improve occupant

survivability and reduce the severity of crash-related injuries. Based on an analysis

of military helicopter crash data, the study also concluded that the use of helmets by

flight crews and medical crews could significantly reduce the risk of serious and fatal

head injuries in a crash. Policymakers may consider whether specific design

guidance or standards for seats, seatbelts, and interior design modifications as well

as operational requirements for equipment such as shoulder harnesses and helmets

could reduce fatalities and mitigate injury risks in air ambulance crashes. Equipment

and design standards and requirements would likely have to strike a balance between

providing flight and medical crews with adequate protective measures while ensuring

that these safety measures do not unduly prevent or interfere with patient care and

other critical mission functions.

Implementing

Principles

System

Safety

and

Risk

Management

The degree to which safety principles are trained and practiced as a matter of

routine within the air ambulance industry is a matter of considerable interest. While

the FAA and trade organizations within the industry have issued guidance to

operators to improve safety practices,49 available accident statistics suggest that these

safety measures either have not yet been adequately adopted and implemented across

the industry or have not been particularly effective. The principal trade organization

of air ambulance operators, the Association of Air Medical Services, recently

launched an initiative, called “Vision Zero”, with the goal of attaining an industrywide commitment to “...to reduce and eliminate errors of consequence—those events

within the transport medicine environment that result in serious injury or fatality –

and to reduce the entire spectrum of helicopter accidents by 80% over the next

48

See also Ira J. Blumen, M.D., and the University of Chicago Aeromedical Safety

Committee, A Safety Review and Risk Assessment in Air Medical Transport, 2002.

49

See, for example: AAMS, AAMS Brief – Part One: Our Commitment to Safety.”

Alexandria, VA: AAMS; AAMS, Air Medical Service Safety Initiative, Alexandria, VA:

AAMS; and Federal Aviation Administration, FAA Notice N8000.301: Operational Risk

Assessment Programs for Helicopter Emergency Medical Services.

CRS-19

decade.”50 While these efforts suggest that the industry as a whole is concerned

about the current level of safety among air ambulance operators and desires to take

positive steps to improve safety, some, including the NTSB, argue that voluntary

measures to improve safety such as this are insufficient, and certain safety-related

changes such as formal dispatch procedures and risk management practices should

require mandatory, industry-wide compliance. Policymakers, either at the FAA or

in Congress, will ultimately have to weigh the merits of this argument and determine

whether the safety benefits of these initiatives outweigh the costs associated with

implementing them.

In its special study examining air ambulance accidents occurring between

January 2002 and January 2005, the NTSB found that a formal risk evaluation of the

mission may have prevented 13 of the 55 accidents reviewed.51 However, the NTSB

found that most operators have not implemented a formal risk evaluation process,

even though guidelines for setting up such a process has been made available by the

FAA. While the FAA has issued guidelines for implementing risk assessment

programs for helicopter air ambulance operations, this material is only advisory in

nature and is not required to be implemented.52 Therefore, the NTSB formally

recommended that the FAA require all air ambulance operators to develop and

implement flight risk evaluation programs and train all employees involved in

decision-making and support of flight operations on participating in these risk

evaluation processes.53

In the airline industry, several initiatives to improve the collection and analysis

of safety-related operational data have taken root and are now common practice. For

example, air carrier flight operational quality assurance (FOQA) programs collect

extensive flight operational data. Using data mining techniques, operations that fall

outside the defined parameters of safe operations are identified and subsequently

investigated to determine the circumstances surrounding the incident, with the goal

of reducing or eliminating events that compromise safety and could lead to an

accident. Many airline safety programs also include internal reporting mechanisms

and specific “whistleblower” protections for employees that identify hazardous

operational practices. Mechanisms have been put in place at several airlines, through

a program called the Aviation Safety Action Program (ASAP), allowing employees

to voluntarily provide confidential reports regarding safety concerns to the FAA with

specific protections against negative consequences, except in those cases involving

suspected criminal actions or drug and alcohol misuse.54 The objective of these

programs is to provide a mechanism for preemptively identifying and correcting

unsafe operations before they lead to an accident. While comprehensive FOQA and

50

AAMS, “Vision Zero: The Time Is Now,” p. 1., AAMS, Alexandria, VA.

51

National Transportation Safety Board, Special Investigation Report on Emergency

Medical Service Operations.

52

See Federal Aviation Administration, FAA Notice N8000.301: Operational Risk

Assessment Programs for Helicopter Emergency Medical Services. August 1, 2005.

53

National Transportation Safety Board, Special Investigation Report on Emergency

Medical Service Operations.

54

See Title 49 USC, § 40123, and Title 14 Code of Federal Regulations, Part 193.

CRS-20

ASAP programs may be too complex to effectively implement in the air ambulance

industry, policymakers may consider whether similar approaches to information

sharing and safety data analysis regarding critical safety issues could be feasibly

implemented across the air ambulance industry.

Training and Procedures for Flight and Medical Crews

It has been reported that, in 2000, representatives from the air ambulance

industry approached the FAA with a proposal to require that air ambulance pilots and

crew members receive training in crew resource management (CRM). This type of

training is mandatory for airline crews and focuses on how to effectively

communicate risk information and use available resources to assess and manage

operational risks.55 However, this proposal has not yet resulted in any FAA

recommendations or regulatory proposals. Presently, there are no specific training

requirement for pilots on topics such as CRM, risk management, and aeronautical

decision making beyond the general understanding of these topics required to obtain

commercial pilot certification and appropriate ratings required for employment, such

as helicopter and instrument ratings. These general requirements are considered

relatively minimal, and many safety experts argue that they do not receive adequate

coverage in general flight training and pilot testing. Moreover, training received on

these topics in the course of general flight training is not tailored to the specific

operational conditions and pressures that a pilot or crew member might experience

in air ambulance operations. Thus, any specific training in dealing with operational

risks unique to the flight environment of air ambulances is provided solely at the

discretion of the operator. While some operators provide this training in various

forms, there is no industry standard for course content or objectives for these types

of training programs.

In the NTSB’s 1988 study of helicopter air ambulance safety, it found that

among the 14 instrument-rated pilots involved in the crashes it examined, only one

was current to fly solely by instruments.56 Similarly, a later analysis of pilot

qualifications among air ambulance operators concluded that, while a greater

percentage of air ambulance operators were instrument rated, a lack of instrument

currency or proficiency could be a detriment because instrument-rated pilots may

overestimate their instrument training skills and press on in deteriorating conditions,

despite not having adequate recent experience and practice with instrument flight

procedures.57 Examining training practices in the medical helicopter industry, the

NTSB found a wide range of approaches to training, and noted that while many

operators had well-defined training programs on paper, actual training did not

adequately address real-world conditions in the operational environment. The NTSB

recommended supplemental training material on aeronautical decision making be

incorporated into initial and recurrent training for pilots. The NTSB also

55

Alan Levin and Robert Davis, “Surge in Crashes Scars Air Ambulance Industry.”

56

National Transportation Safety Board, Commercial Emergency Medical Service

Helicopter Operations.

57

Ira J. Blumen, M.D., and the University of Chicago Aeromedical Safety Committee, A

Safety Review and Risk Assessment in Air Medical Transport, 2002.

CRS-21

recommended that guidelines for FAA inspectors be revised to include reviews and

approvals of initial and recurrent training for pilots to ensure that they provide

adequate levels of instruction on poor weather operations and accident scene

procedures.58 The recently initiated FAA targeted inspection program for helicopter

air ambulance operators59 appears to directly address these concerns, and therefore,

the effectiveness of ongoing FAA inspections of helicopter air ambulance operators

may be of particular interest as an issue for oversight of the FAA.

Besides flight crew training, there has also been a recent emphasis on providing

aviation-specific training to other members of the air ambulance team, principally

communications specialists that dispatch and monitor air ambulance flights. The

FAA has also suggested, but does not yet require, special training for ground

communications specialists that dispatch and track air ambulance flights covering

aviation weather, flight operations, and flight tracking procedures.60 Unlike the

airlines, which must used FAA-certified dispatchers, air ambulance pilots are

typically dispatched by EMS dispatchers or communication specialists who typically

do not receive any formal training in aviation operations or aviation weather. The

NTSB has recommended that all air ambulance operators implement formal flight

dispatch procedures utilizing dedicated aviation dispatchers with formal aviationspecific knowledge and experience that can assist pilots in assessing weather data,

provide comprehensive flight following, and aid pilots in making informed decisions

whether to accept or continue a mission.61 Policymakers will need to determine the

feasability of requiring dedicated flight dispatchers in the air ambulance environment,

and whether these services require an FAA certified dispatcher approved under

existing FAA training and certification requirements for flight dispatchers.

Alternatively, policymakers may evaluate whether mandatory training of existing

emergency medical communication specialists that work with or for air ambulance

operators on aviation-specific dispatch procedures, aviation weather, aircraft

capabilities, flight following, and so on, would meet the intent of this

recommendation. At least one company has already developed aviation-specific

training for emergency medical communication specialists conforming to FAA

recommended training for ground communication specialists and hopes that this form

of training will be mandated for the entire industry.62

58

National Transportation Safety Board, Commercial Emergency Medical Service

Helicopter Operations.

59

Federal Aviation Administration. Flight Standards Handbook Bulletin for Air

Transportation (HBAT) 06-02A: Helicopter Emergency Medical Services (HEMS) Loss of

Control (LOC) and Controlled Flight Into Terrain (CFIT) Accident Avoidance Programs.

Effective 1/23/2006, Revised 3/14/2006.

60

Ibid.

61

National Transportation Safety Board, Special Investigation Report on Emergency

Medical Service Operations.

62

“Air Dispatcher Training Should Make EMS Flights Safer.” Air Safety Week, April 24,

2006, p. 3.

CRS-22

Technology to Improve Safety in Low Visibility Conditions

Various technologies are available to improve visibility and pilot situation

awareness of terrain, obstacles, and weather. While these technologies may be of

benefit to improve the safety of air ambulance missions, some operators have

expressed concern over the cost of installing and maintaining these systems if doing

so was made mandatory as the NTSB has recommended. Others have questioned

whether these technologies are appropriately suited for air ambulance use, or whether

modifications may be needed to tailor these devices to the unique mission profiles

and needs of air ambulance operators, particularly for use on helicopter air

ambulance missions.

Terrain Warning Systems. The NTSB’s recent assessment of air ambulance

safety included a recommendation to equip all helicopters and aircraft used in

emergency medical services with terrain awareness and warning systems (TAWS,

previously referred to as enhanced ground proximity warning systems or EGPWS).63

These devices provide pilots with visual displays and audible alerts for terrain

avoidance. Advanced Class A TAWS (TAWS-A) that rely on detailed terrain

databases, Global Positioning System (GPS) data or other means of precise aircraft

positioning, and radio altimeters to provide height above terrain information are

already required on all commercially operated aircraft with 10 or more passenger

seats. Slightly less sophisticated versions of TAWS, called Class B TAWS (TAWSB), which do not include radio altimeter height above terrain inputs, are required on

all turbojets and turboprops, whether commercially or privately operated, having six

or more passenger seats. A typical TAWS-B installation may cost between $10,000

and $30,000 per aircraft depending on existing equipment configurations. While

some larger fixed-wing air ambulance aircraft may already fall under the requirement

for TAWS-B installation if they have seating for six or more passengers, most

helicopter and airplanes used as air ambulances do not. The NTSB specifically

recommended that air ambulance operators install TAWS and provide adequate

training in the use of TAWS to their flight crews, although it did not specify whether

these aircraft should be equipped with TAWS-A or TAWS-B.64 The NTSB believes

that TAWS could help prevent many controlled flight into terrain or CFIT accidents,

which, as previously noted constituted one of the two most common causal factors

cited in air ambulance accidents.

Some operators have voiced concern, however, that false alarms generated by

the TAWS systems could distract pilots. These operators are worried that high false

alarm rates – particularly among helicopter air ambulances that frequently operate in

close proximity to terrain in a manner not typical of other aircraft and flight

operations – could largely negate any benefit that TAWS may provide in terms of

improving pilot situation awareness regarding terrain clearance. While false alarms

are a potential concern when using TAWS systems because they may distract pilots,

the NTSB and other aviation safety experts believe that the benefits of TAWS in

improving pilot situation awareness regarding the surround terrain far outweigh any

63

National Transportation Safety Board, Special Investigation Report on Emergency

Medical Service Operations.

64

Ibid.

CRS-23

negative effects that might occur due to false alarms. However, further operational

testing of TAWS usage in simulated air ambulance missions may be needed to fully

assess the suitability of TAWS in helicopter air ambulance operations.

Technologies to Enhance In-Flight Visibility. In addition to TAWS, a

variety of technologies are available to improve pilot situation awareness regarding

terrain and obstacles during low visibility conditions and at night. As shown in

Figure 2, nighttime visual conditions were a contributing factor in 14% and reduced

visibility due to weather was a factor in 9% of the helicopter air ambulance crashes

examined between 1991 and 2004. Technologies to improve visibility under these

restricted visibility conditions and at night could mitigate these types of accidents.

One broad category of available technologies to improve pilot vision, referred

to as night vision imaging systems (NVIS), rely on various forms of infrared sensors

or cameras to enhance a pilots view of the outside scene and avoid terrain and

obstructions at night. One example of NVIS technology is night vision goggles

NVGs), used extensively in military helicopter operations, which can be worn by

pilots to improve out-the-window visibility and aid in the avoidance of terrain and

obstacles, such as power lines. An FAA study found that properly used NVGs can

increase safety, enhance situation awareness, and reduce pilot workload during flights

at night.65 Although the FAA has approved the use of NVGs and recommends they

be deployed for helicopter air ambulance operations, the NTSB found that most

operators do not use NVGs because they have only been recently made available for

non-military aviation use, equipping aircraft and training pilots is expensive, and they

can only be used effectively in sparsely populated areas where there isn’t much

ambient light. While the NTSB found that the use of night vision goggles may have

mitigated 13 of the 55 accidents it examined in its 2006 special study, it did not

formally recommend NVG usage, recognizing that these systems are not usable in

all situations.

Besides NVGs, other imaging systems are available for aviation use. Forward

looking infrared cameras (FLIR) can provide enhanced images of night and low

visibility scenes. FLIR images can be projected on screens in the cockpit or through

head-up displays (HUDs) that overlay the enhanced image on top of the out the

window scene. Recently certified enhanced vision systems (EVS) use similar

principles to present images generated from special infrared cameras in the cockpit,

usually on a HUD. EVS systems have been specifically certified by the FAA for use

in instrument flight operations for flying approaches to airports in poor visibility and

at night and several business and commercial jets have been equipped with this new

technology. Such systems could potentially be used to improve visibility and

situation awareness in air ambulance operations, especially for helicopter air

ambulance operations that fly into unprepared landing sites where navigational aids

and instrument approach procedures are not available to guide the pilot.

65

W. T. Sampson, G. B. Simpson, and D. L. Green. Night Vision Goggles in Emergency

Medical Services (EMS) Helicopter. DOT/FAA/RD-94/21 (1994): Federal Aviation

Administration,

CRS-24

In addition to the aforementioned technologies that rely on cameras or sensors

to enhance vision by capturing information outside the spectrum of what is visible

to the human eye, the FAA has also approved synthetic vision systems (SVS) for

operational use. Unlike EVS, which relies on sensors or cameras to collect

information from the outside scene, SVS relies on precise positioning, principally

from very precise GPS receivers,66 and accurate onboard terrain databases to present

pilots with a computer-generated image of the known terrain features and obstacles

in and around the aircraft’s flight path. These images can be overlaid on top of

navigational instruments, or like EVS, can be projected on a head-up display to

overlay on top of the out-the-window view. Coupled with highly accurate

positioning information, SVS can potentially provide helicopter air ambulance pilots

with accurate navigation and terrain avoidance capabilities in low visibility and night

conditions. As these technologies further advance, some combination of EVS and

SVS imaging may be able to provide air ambulance pilots with situation awareness

of terrain and obstacles that matches, or in some cases, surpasses visual capabilities

in unrestricted daylight conditions. Systems that combine EVS and SVS imaging are

currently in the testing and certification process and may provide a means to enhance

cockpit situation awareness in air ambulance operations in the near future.67

66

Presently, the greatest accuracy in positioning can be obtained from the use of GPS

augmented with Wide Area Augmentation System (WAAS) inputs that improve position

accuracy.

67

Glenn Connor. “From Air to Ground.” Professional Pilot, April 2006, 54-60.

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