    [House Hearing, 111 Congress]
    [From the U.S. Government Publishing Office]

                     OVERSIGHT OF HELICOPTER MEDICAL SERVICES

    =======================================================================

                                    (111-23)

                                    HEARING

                                   BEFORE THE

                                SUBCOMMITTEE ON
                                    AVIATION

                                     OF THE

                                  COMMITTEE ON
                       TRANSPORTATION AND INFRASTRUCTURE
                            HOUSE OF REPRESENTATIVES

                         ONE HUNDRED ELEVENTH CONGRESS

                                 FIRST SESSION

                                   ----------

                                 APRIL 22, 2009

                                   ----------

                           Printed for the use of the
                 Committee on Transportation and Infrastructure

                    OVERSIGHT OF HELICOPTER MEDICAL SERVICES

                    OVERSIGHT OF HELICOPTER MEDICAL SERVICES

    =======================================================================

                                    (111-23)

                                    HEARING

                                   BEFORE THE

                                SUBCOMMITTEE ON
                                    AVIATION

                                     OF THE

                                  COMMITTEE ON
                       TRANSPORTATION AND INFRASTRUCTURE
                            HOUSE OF REPRESENTATIVES

                         ONE HUNDRED ELEVENTH CONGRESS

                                 FIRST SESSION

                                   __________

                                 APRIL 22, 2009

                                   __________

                           Printed for the use of the
                 Committee on Transportation and Infrastructure

                                   ----------
                             U.S. GOVERNMENT PRINTING OFFICE

    49-001 PDF                       WASHINGTON : 2009

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                 COMMITTEE ON TRANSPORTATION AND INFRASTRUCTURE

                     JAMES L. OBERSTAR, Minnesota, Chairman

    NICK J. RAHALL, II, West Virginia,   JOHN L. MICA, Florida
    Vice Chair                           DON YOUNG, Alaska
    PETER A. DeFAZIO, Oregon             THOMAS E. PETRI, Wisconsin
    JERRY F. COSTELLO, Illinois          HOWARD COBLE, North Carolina
    ELEANOR HOLMES NORTON, District of   JOHN J. DUNCAN, Jr., Tennessee
    Columbia                             VERNON J. EHLERS, Michigan
    JERROLD NADLER, New York             FRANK A. LoBIONDO, New Jersey
    CORRINE BROWN, Florida               JERRY MORAN, Kansas
    BOB FILNER, California               GARY G. MILLER, California
    EDDIE BERNICE JOHNSON, Texas         HENRY E. BROWN, Jr., South
    GENE TAYLOR, Mississippi             Carolina
    ELIJAH E. CUMMINGS, Maryland         TIMOTHY V. JOHNSON, Illinois
    LEONARD L. BOSWELL, Iowa             TODD RUSSELL PLATTS, Pennsylvania
    TIM HOLDEN, Pennsylvania             SAM GRAVES, Missouri
    BRIAN BAIRD, Washington              BILL SHUSTER, Pennsylvania
    RICK LARSEN, Washington              JOHN BOOZMAN, Arkansas
    MICHAEL E. CAPUANO, Massachusetts    SHELLEY MOORE CAPITO, West
    TIMOTHY H. BISHOP, New York          Virginia
    MICHAEL H. MICHAUD, Maine            JIM GERLACH, Pennsylvania
    RUSS CARNAHAN, Missouri              MARIO DIAZ-BALART, Florida
    GRACE F. NAPOLITANO, California      CHARLES W. DENT, Pennsylvania
    DANIEL LIPINSKI, Illinois            CONNIE MACK, Florida
    MAZIE K. HIRONO, Hawaii              LYNN A WESTMORELAND, Georgia
    JASON ALTMIRE, Pennsylvania          JEAN SCHMIDT, Ohio
    TIMOTHY J. WALZ, Minnesota           CANDICE S. MILLER, Michigan
    HEATH SHULER, North Carolina         MARY FALLIN, Oklahoma
    MICHAEL A. ARCURI, New York          VERN BUCHANAN, Florida
    HARRY E. MITCHELL, Arizona           ROBERT E. LATTA, Ohio
    CHRISTOPHER P. CARNEY, Pennsylvania  BRETT GUTHRIE, Kentucky
    JOHN J. HALL, New York               ANH ``JOSEPH'' CAO, Louisiana
    STEVE KAGEN, Wisconsin               AARON SCHOCK, Illinois
    STEVE COHEN, Tennessee               PETE OLSON, Texas
    LAURA A. RICHARDSON, California
    ALBIO SIRES, New Jersey
    DONNA F. EDWARDS, Maryland
    SOLOMON P. ORTIZ, Texas
    PHIL HARE, Illinois
    JOHN A. BOCCIERI, Ohio
    MARK H. SCHAUER, Michigan
    BETSY MARKEY, Colorado
    PARKER GRIFFITH, Alabama
    MICHAEL E. McMAHON, New York
    THOMAS S. P. PERRIELLO, Virginia
    DINA TITUS, Nevada
    HARRY TEAGUE, New Mexico
    VACANCY

                                      (ii)

                            Subcommittee on Aviation

                     JERRY F. COSTELLO, Illinois, Chairman

    RUSS CARNAHAN, Missouri              THOMAS E. PETRI, Wisconsin
    PARKER GRIFFITH, Alabama             HOWARD COBLE, North Carolina
    MICHAEL E. McMAHON, New York         JOHN J. DUNCAN, Jr., Tennessee
    PETER A. DeFAZIO, Oregon             VERNON J. EHLERS, Michigan
    ELEANOR HOLMES NORTON, District of   FRANK A. LoBIONDO, New Jersey
    Columbia                             JERRY MORAN, Kansas
    BOB FILNER, California               SAM GRAVES, Missouri
    EDDIE BERNICE JOHNSON, Texas         JOHN BOOZMAN, Arkansas
    LEONARD L. BOSWELL, Iowa             SHELLEY MOORE CAPITO, West
    TIM HOLDEN, Pennsylvania             Virginia
    MICHAEL E. CAPUANO, Massachusetts    JIM GERLACH, Pennsylvania
    DANIEL LIPINSKI, Illinois            CHARLES W. DENT, Pennsylvania
    MAZIE K. HIRONO, Hawaii              CONNIE MACK, Florida
    HARRY E. MITCHELL, Arizona           LYNN A. WESTMORELAND, Georgia
    JOHN J. HALL, New York               JEAN SCHMIDT, Ohio
    STEVE COHEN, Tennessee               MARY FALLIN, Oklahoma
    LAURA A. RICHARDSON, California      VERN BUCHANAN, Florida
    JOHN A. BOCCIERI, Ohio               BRETT GUTHRIE, Kentucky
    NICK J. RAHALL, II, West Virginia
    CORRINE BROWN, Florida
    ELIJAH E. CUMMINGS, Maryland
    JASON ALTMIRE, Pennsylvania
    SOLOMON P. ORTIZ, Texas
    MARK H. SCHAUER, Michigan
    VACANCY
    JAMES L. OBERSTAR, Minnesota
      (Ex Officio)

                                     (iii)

                                    CONTENTS

                                                                       Page

    Summary of Subject Matter........................................   vii

                                   TESTIMONY

    Allen, John, Director, Flight Standards Service, Federal Aviation
      Administration.................................................    12
    Bass, Dr. Robert, Chair, Air Medical Committee, the National
      Association of State EMS Officials.............................    30
    Dillingham, Dr. Gerald, Director, Physical Infrastructure Issues,
      U.S. Government Accountability Office..........................    12
    Fornarotto, Hon. Christa, Acting Assistant Secretary for Aviation
      and International Affairs, U.S. Department of Transportation...    12
    Frazer, RN, CMTE, Eileen, Executive Director, Commission on
      Accreditation of Medical Transport Systems.....................    30
    Friedman, Stacey, Founder, SafeMedFlight: Family Advocates For
      Air Medical Safety.............................................    30
    Judge, EMTP, Thomas P., Executive Director, LifeFlight of Maine,
      Chair, the Patient First Air-Ambulance Alliance................    30
    Kinkade, Sandra, President, Association of Air Medical Services..    30
    Salazar, Hon. John T., a Representative in Congress from the
      State of Colorado..............................................    10
    Stackpole, Jeff, Council Member, Professional Helicopter Pilots
      Association....................................................    30
    Sumwalt, III, Hon. Robert L., Board Member, National
      Transportation Safety Board....................................    12
    Yale, Craig, Executive Vice President, Air Methods Corporation,
      on Behalf of the Air Medical Operators Association.............    30
    Zuccaro, Matthew S., President, Helicopter Association
      International..................................................    30

              PREPARED STATEMENTS SUBMITTED BY MEMBERS OF CONGRESS

    Carnahan, Hon. Russ, of Missouri.................................    47
    Costello, Hon. Jerry F., of Illinois.............................    48
    Johnson, Hon. Eddie Bernice, of Texas............................    56
    Mitchell, Hon. Harry E., of Arizona..............................    60
    Oberstar, Hon. James L., of Minnesota............................    61
    Salazar, Hon. John T., of Colorado...............................    65

                   PREPARED STATEMENTS SUBMITTED BY WITNESSES

    Allen, John and Hon. Christa Fornarotto, joint statement.........    69
    Bass, Dr. Robert.................................................    90
    Dillingham, Dr. Gerald...........................................    96
    Frazer, RN, CMTE, Eileen.........................................   124
    Friedman, Stacey.................................................   138
    Judge, EMTP, Thomas P............................................   149
    Kinkade, Sandra..................................................   187
    Stackpole, Jeff..................................................   202
    Sumwalt, III, Hon. Robert L......................................   214
    Yale, Craig......................................................   229
    Zuccaro, Matthew S...............................................   260

                           SUBMISSIONS FOR THE RECORD

    Allen, John, Director, Flight Standards Service, Federal Aviation
      Administration, responses to questions from the Subcommittee...    80
    Dillingham, Dr. Gerald, Director, Physical Infrastructure Issues,
      U.S. Government Accountability Office, responses to questions
      from the Subcommittee..........................................   117
    Fornarotto, Hon. Christa, Acting Assistant Secretary for Aviation
      and International Affairs, U.S. Department of Transportation,
      responses to questions from the Subcommittee...................    85
    Judge, EMTP, Thomas P., Executive Director, LifeFlight of Maine,
      Chair, the Patient First Air-Ambulance Alliance, responses to
      questions from Rep. Costello...................................   161
    Sumwalt, III, Hon. Robert L., Board Member, National
      Transportation Safety Board, responses to questions from the
      Subcommittee...................................................   224
    Yale, Craig, Executive Vice President, Air Methods Corporation,
      on Behalf of the Air Medical Operators Association, responses
      to questions from the Subcommittee.............................   251

                            ADDITIONS TO THE RECORD

    Bean, Danielle, written statement................................   267
    Brady, Laurie, written statement.................................   271
    McGlew, Susan, written statement.................................   273
    National EMS Pilots Association, Kent Johnson, President, written
      statement......................................................   275
    Schiller, Brian T., written statement............................   311
    Schumm, Tracy, written statement.................................   314
    Terry, Cece, written statement...................................   316

    [GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]

              HEARING ON OVERSIGHT OF HELICOPTER MEDICAL SERVICES

                                  ----------

                           Wednesday, April 22, 2009

                       House of Representatives
        Committee on Transportation and Infrastructure,
                                      Subcommittee on Aviation,
                                                        Washington, DC.
        The Subcommittee met, pursuant to call, at 10:00 a.m., in
    Room 2167, Rayburn House Office Building, the Honorable Jerry
    F. Costello [chairman of the Subcommittee] presiding.
        Mr. Costello. The Subcommittee will come to order. The
    Chair will ask all Members, staff, and everyone in the room to
    turn electronic devices off or on vibrate.
        The purpose of the hearing is to hear testimony on the
    oversight of helicopter medical services. We have a number of
    witnesses today, two panels, that I hope other Members will be
    here to hear their testimony and to ask questions.
        We have on our first panel one of our colleagues, a Member
    of the House, that will be testifying, the Honorable John
    Salazar, from Colorado's 3rd District.
        I will offer an opening statement. I will ask, then, the
    Ranking Member of the Full Committee to give his opening
    statement and the Ranking Member of the Subcommittee.
        I welcome everyone to the Aviation Subcommittee hearing
    today on oversight of the helicopter medical services. This
    hearing will examine two issues: first, the safety of
    helicopter emergency medical services, or helicopter EMS; and,
    second, the State regulation of helicopter EMS.
        The Federal Aviation Administration regulates helicopter
    and the pilot, while States regulate the medical care that a
    patient receives while on board the aircraft. This hearing is
    an opportunity to discuss how the aviation industry,
    government, and the health care community can work together
    towards a common goal of enhanced helicopter EMS safety.
        The helicopter EMS industry provides an important service
    by transporting seriously ill patients to emergency care
    facilities and high level trauma centers. However, helicopter
    air ambulance operates in challenging conditions, such as
    flying in bad weather, going into unfamiliar landing sites, and
    operating at night.
        According to the National Transportation Safety Board,
    approximately 400,000 patients and transplant organs each year
    are safely transported by helicopter, saving countless lives.
    Unfortunately, lives have been lost as well. Between 1998 and
    2008, there were 146 helicopter EMS accidents, with 131
    fatalities, the greatest number of accidents in any 11 month
    period occurring between December 2007 and October 2008
    resulting in 13 accidents and 35 fatalities.
        I want to acknowledge the family members of those who lost
    their lives in helicopter EMS accidents who are here with us
    today. On behalf of this Subcommittee and each of our Members,
    I offer our condolences.
        In 1988, the NTSB conducted a study of helicopter EMS and
    issued 19 safety recommendations. In January 2006, 18 years
    later, the NTSB conducted another special investigation after
    an increase in accidents. As a result of this investigation,
    the NTSB issued four safety recommendations to the FAA and
    added helicopter EMS to its most wanted list in 2009.
        The NTSB also held a four-day public hearing on helicopter
    EMS operations in February. I look forward to hearing our NTSB
    witness explain the recommendations of its four-day hearing. I
    want a progress report on how the FAA plans to proceed
    following that hearing, what the agency is doing to address the
    safety issues that were raised.
        I look forward to an update on the Government
    Accountability, the GAO 2007 report that I requested, which
    recommended that the FAA identify and collect data to better
    understand the air ambulance industry. Without this data, it
    would be difficult to know how to address the problem.
        In addition, Congressman Salazar and Congressman Lungren
    introduced legislation addressing many helicopter EMS safety
    issues. I thank Congressman Salazar for testifying here today
    regarding his bill.
        We are here today because we are committed to preventing
    helicopter EMS accidents. I look forward to the witnesses'
    testimony on current and future actions industry and government
    can take to improve helicopter EMS safety. Safety is and must
    always be priority one.
        This brings me to the second issue that we will explore at
    this hearing today, State regulation of helicopter EMS.
    Currently, States have the authority to regulate medical care
    inside the aircraft, including establishing minimum
    requirements for medical equipment, as well as training and
    licensing requirements of the medical crew. My home State of
    Illinois requires EMS helicopters to be equipped with a cardiac
    monitor and an extra battery, a defibrillator that is
    adjustable to all age groups, an external pacemaker, two
    sources of oxygen, in addition to other medical equipment.
        However, the Airline Deregulation Act of 1978 stipulates
    that these States do not have the authority to regulate rates,
    routes, or services of air carriers.
        Several States have tried to adopt regulations pertaining
    to helicopter EMS that control items other than medical care,
    such as the Certificate of Need program, rate setting, and
    limitation on geographic service areas. Courts and the
    Department of Transportation have found that many of these
    State regulations were essentially economic regulations of air
    carriers that were preempted by ADA, or the Airline
    Deregulation Act.
        For example, a Federal court in North Carolina recently
    found that the State regulations establishing a Certificate of
    Need program limiting the number of helicopter EMS operators in
    the State was preempted by ADA. Accordingly, some are calling
    for clarification of the ADA to allow States to have a greater
    hand in regulating aspects of helicopter EMS that may be
    considered to be preempted by the ADA. They argue that States
    regulate ambulances on the ground; therefore, they should be
    able to regulate ambulances in the air.
        However, the issue is not that simple. Air medical
    transport is an interstate operation. I have concerns about
    allowing each State to separately regulate helicopter EMS
    services.
        In 2007, the National Academy of Sciences issued a report
    stating that there is a need to address inefficiencies and
    problems with the entire emergency medical services, and by
    trying to tackle the issue of State regulation of helicopter
    EMS, we may be missing out on ``the big picture issues'' of the
    EMS system as a whole.
        Congressman Altmire and Congresswoman Miller introduced
    legislation addressing State regulation of medical helicopters.
    I thank them for bringing these issues before the Subcommittee.
    The provisions in this legislation are extremely complex, and I
    hope to have a good discussion of these issues.
        Before I recognize Mr. Petri for his opening statement, I
    ask unanimous consent to allow two weeks for all Members to
    revise and extend their remarks, and to permit the submission
    of additional statements and materials by witnesses and
    Members. Without objection, so ordered.
        At this time, the Ranking Member of the Full Committee, Mr.
    Mica is here, and I understand has an opening statement or a
    comment.
        Mr. Mica, you are recognized.
        Mr. Mica. Well, thank you for recognizing me, and also
    thank you for convening this hearing. I also want to say that I
    appreciated your opening remarks. Very well said. I think you
    have covered the issues and challenges that we face on this
    issue.
        I requested a hearing back in September, and I think Mr.
    Petri did in the earlier part of this year. From time to time,
    as a former Chair of the Aviation Subcommittee, I think there
    are issues that reach a certain level that we can't ignore them
    and we must address them, and I am pleased that this hearing is
    going to address what I considered last year to be an
    unacceptable level of fatalities with medical assistance
    helicopters. Their intention is great and they save thousands
    of lives every year, but sometimes we have experienced the
    heartbreak, in fact, I have known folks that have unfortunately
    lost individuals in that type of accident trying to save their
    life, but their life was lost in the course of that rescue
    effort.
        I don't have answers, Mr. Chairman or Mr. Ranking Member,
    but I think that we can take from this hearing. We have several
    Members with some well-intended legislative proposals, and I
    think we need to very seriously look at those.
        We don't want the cure, though, to be worse than the
    problem that we are experiencing, and we do have, as you
    pointed out in your opening statement, multi-jurisdictional
    layers of responsibility; there are State issues here, Federal,
    medical. Do we regulate by law? Should FAA adopt additional
    measures?
        Most of the accidents have occurred either in bad weather
    or at night, I think our staff reviewed, and that is of
    particular concern to me. I am not sure if we have technologies
    to deal with all of this, because most of these helicopters fly
    at very low levels, and they are going into a disaster scene to
    begin with, usually in bad weather conditions or at night.
        So I do think that this hearing will be most helpful in
    hearing from experts, and hopefully they can give us some
    concrete solutions or some steps that we can take. So I look
    forward to working with you. Thank you for conducting this
    hearing. I won't be able to stay for the whole thing. As you
    know, Mr. Oberstar and I are committed on a couple of important
    issues today. I will follow up very carefully with you and
    support whatever you and Mr. Petri can come up with as positive
    solutions. Thank you. I yield back.
        Mr. Costello. The Chair thanks the Ranking Member and now
    recognizes Mr. Altmire.
        Mr. Altmire. Thank you, Mr. Chairman. I want to commend you
    for holding this hearing and the two important issues
    surrounding helicopter medical services, aviation safety and
    patient safety. When we see the crashes on the front page of
    the newspapers, we are horrified and we know that we must act
    to address aviation safety. But so too must we address patient
    safety. The stories aren't hitting the front page of the
    newspapers in same dramatic way, but they are numerous and they
    are real. Patients are being harmed and put at risk everyday by
    a broken air medical system that is supposed to protect them.
        There are numerous stories illustrating patient safety
    problems in our air medical system. These stories include
    infants arriving at hospitals code blue with temperatures 10
    degrees below normal because the helicopter was not heated. In
    one case, a premature infant was also improperly intubated and
    secured during the flight. Patients have experienced delayed
    transports when air medical systems stack the flights and say
    they will transport a patient, even though they have to wait
    until the helicopter frees up. Patients have died during these
    waiting periods, even though a closer helicopter was available
    but never called.
        Requests to move medical helicopters off hospital helipads
    to accommodate other incoming medical helicopters for patient
    transports have been refused. There have been instances of
    blatant inadequacy in the structure of the aircraft itself, in
    one case resulting in a child receiving a second degree burn
    and requiring skin grafts because the bed he was riding in was
    too close to the heating vent on the helicopter.
        Unfortunately, these are not isolated instances. These are
    real patients who have been harmed or put at risk in areas
    where there is fierce and unregulated competition among medical
    helicopters. When there is economic pressure to fly as much as
    possible and as cheaply as possible, undue risks are inevitably
    taken.
        States must have the right to regulate competition to
    ensure that business interests do not trump patient safety.
    H.R. 978, which Representative Miller has joined me in
    cosponsoring, would create a protected sphere in which States
    can regulate helicopter medical services notwithstanding the
    Airline Deregulation Act. This bill is endorsed by 55 air
    medical programs, 7 Part 135 operators, and 11 health
    organizations, including the National World Health Association
    and the National EMS Physicians Association, and I am pleased
    to announce that just today, in the Senate, companion
    legislation was introduced by Senators McCaskill and Snowe. S.
    848 incorporates some of the helpful suggestions to this
    Committee following recommendations by the FAA and the DOT.
        While the FAA regulates the aviation aspects of air
    ambulances, I believe States must be able to fully regulate the
    medical part, aboard the helicopter and beyond. Our bill would
    allow States to regulate in the following ways: by ensuring
    quality care aboard the helicopter with the medically necessary
    equipment, aircraft attributes and qualified personnel safety
    for severely sick and injured patients; coordinate HMS services
    as part of the State EMS system so patients are transported to
    the right place at the right time; determine how helicopters
    are needed, establishing base locations and designating service
    areas to back up protocols to better prevent air medical
    programs from call-jumping, stacking flights, or fighting for
    patient transports; requiring programs to be available 24/7 and
    preventing them from performing wallet biopsies on patients
    needing emergency transport.
        These tools would be available for States to better
    regulate helicopter medical services and protect their
    citizens. This bill does not impede access to rural and
    underserved areas; it provides States the tools to improve
    access to underserved areas by enabling them to better ensure
    service coverage. It also allows States to regulate over-
    saturated markets where regulated competition is producing the
    problems I have outlined. It does not affect rates. Rates are
    simply not within the protected sphere of State regulation, and
    the ADA still prohibits States from regulating rates. It does
    not prevent interstate movement of helicopters. The legislation
    affects point-to-point transports within the State only. It
    does not impede on FAA authority over aviation safety. FAA
    flight safety rules supersede State medical regulations.
        I have been pleased to be working with the Subcommittee,
    the FAA, and the DOT, and other interested parties to identify
    clarifications that can be provided to improve this
    legislation, and I very much appreciate the input of all these
    groups.
        As a final note, Mr. Chairman, let me stress that the ADA
    preemption provision has generally worked in the aviation
    industry for reducing costs and improving services. However, it
    is not working in helicopter medical services. Instead, it has
    resulted in lowering the standards of care and higher costs for
    patients and insurers.
        I appreciate the consideration of this Subcommittee and
    Chairman Costello in working to address patient safety. We are
    all trying to protect the same critically ill patients being
    transported by medical helicopters, and I look forward to
    continuing working with everyone involved.
        Thank you, Mr. Chairman.
        Mr. Costello. The Chair thanks the gentleman from
    Pennsylvania and thanks him for his leadership on this issue.
    In addition to Ranking Member Mica and Petri requesting this
    hearing, Mr. Altmire requested the hearing as well, and we
    appreciate your leadership and look forward to working with you
    on your legislation and trying to come up with a solution that
    can address the problem that we are all concerned about.
        The Chair now recognizes the Ranking Member of the
    Subcommittee, Mr. Petri.
        Mr. Petri. Thank you for scheduling this hearing, Mr.
    Chairman.
        And my colleague, John Salazar, thanks you for your
    patience as you listen to all of us give our five minute
    remarks. I have a lot of fond memories of visiting the rail
    safety and experimental station in your district in Colorado
    some years ago.
        From December 2007 to October 2008, 35 people lost their
    lives in 13 helicopter emergency medical services accidents,
    the most ever in an 11-month period. One of these accidents
    where the pilot, flight paramedic, and flight physician were
    killed occurred last year in my own State, in La Crosse,
    Wisconsin.
        Any aviation accident is a terrible heartbreaking event. In
    helicopter EMS crashes, the professionals who risk their lives
    to help others are often among those who are killed.
        Mr. Mica and I and Mr. Altmire requested this hearing to
    provide the opportunity for those directly involved to share
    their expertise and insights on how to address this important,
    but complicated, aviation safety issue.
        I understand that there is no silver bullet to aviation
    safety, and helicopter EMS is no exception. It will take the
    focus and effort of Federal regulators and industry
    stakeholders to improve the safety of helicopter EMS flights. I
    am interested in learning about the ongoing regulatory efforts
    at the FAA to address helicopter EMS safety. I am also
    interested to hear what technologies made pilots and operators
    in their singular mission of safe patient transport.
        As we take up possible legislation, we must carefully
    consider congressional mandates for helicopter EMS equipment or
    operating standards. It is important to thoroughly explore
    which technologies make the best sense to improve aviation
    safety. But, at the same time, we must give appropriate
    attention to the unique operating environment and the recently
    updated regulatory structure under which helicopter EMS flights
    operate.
        H.R. 1201, introduced by Mr. Salazar and Mr. Lungren,
    highlights the safety areas, technology, and operating
    standards to be explored by this Subcommittee today. We have
    witnesses ready to discuss these issues, and I look forward to
    hearing our panelists' viewpoints on the proposed legislation.
        It is my understanding we will also consider H.R. 978, as
    introduced by Mr. Altmire and Mrs. Miller. Their bill seeks to
    clarify--and some may argue expand--State authority over air
    medical flights. I believe this Committee must carefully
    consider the impact H.R. 978 could have on FAA regulatory
    oversight of aviation safety. If the helicopter EMS sector of
    the aviation industry were to be treated differently in terms
    of State versus Federal oversight, a number of issues come to
    mind. For instance, would other sectors of the aviation
    community, all unique in their own right, feel justified in
    demanding their own carve-out from Federal regulations?
        Federal oversight of the aviation industry has long ensured
    one standard of safety oversight and operational requirements
    nationwide. It has also provided a level playing field for
    competition. Across the aviation industry, competition has had
    a positive effect on safety and prices available to consumers.
        The delegation of economic regulatory authority from the
    Department of Transportation to the various States, as directed
    in H.R. 978, is a fundamental shift in oversight of the air
    transport industry. It is the responsibility of this
    Subcommittee to understand and consider all potential effects
    on aviation safety, competition, and access to helicopter EMS
    care for consumers before such a monumental shift is mandated.
        Again, I look forward to a lively discussion on the issues
    and, in the interest of time, I want to thank the witnesses for
    their participation and yield back the balance of my time.
        Mr. Costello. The Chair thanks the Ranking Member and now
    recognizes the distinguished Chairman of the Full Committee,
    Chairman Oberstar.
        Mr. Oberstar. Thank you very much, Mr. Chairman, Mr. Petri,
    both, for holding this hearing and inquiring into this
    extremely important subject matter that frankly has a great
    many people deeply concerned.
        You have quite a lineup of witnesses today, including our
    former Committee colleague, Mr. Salazar. He is still an
    emeritus Member of the Committee. We welcome him back, these
    refugees who take respite in another Committee.
        But you are always on call, I want you to know, Mr.
    Salazar.
        I have had time to reflect a bit, Mr. Chairman, on the
    previous hearing in this Subcommittee on the U.S. Airways
    remarkable survival of a bird strike, and after reviewing the
    testimony and thinking it through, it seems to me that we ought
    to have perhaps not a hearing, but perhaps an in camera, as is
    quaintly said in Latin, discussion with NTSB, with the FAA,
    with Boeing and Airbus, and discuss the adequacy of testing of
    engines with bird strikes.
        As I reviewed the testimony, review the literature in the
    field, it seemed to me that the entire testing process is
    inadequate. One bird 1.2, 1.4, 2.5 pounds, largest used was a 7
    pound bird. Nothing of the size of the Canada geese, which are
    like--I don't want to offend Canada geese lovers; it is pretty
    hard to find any, but they are winged very heavy rats, as my
    friends on the docks call them; and they can rise to 20 to 25
    pounds. Many of them are inept at flying because they spend so
    much time on the ground, those domesticated critters. They
    haven't used the central Mississippi flyway in years, nor the
    east coast flyway in years. But they do manage to get up to
    3,000 feet.
        And while FAA and U.S. Airways and Airbus and the engine
    manufacturers, CFM, all considered it to be a success that
    there was not an uncontained engine failure, it still was a
    failure, and I think we need to have them come with some
    technical specifications and review with us the adequacy of the
    testing, the construction of engines, and not limit this
    roundtable discussion. It ought to be inclusive on the
    Committee, we don't need to have a public hearing on the
    subject, but I think we need to have a very in-depth technical
    review. There are only a handful of engine manufacturers--
    Snecma, Pratt and Whitney, GE, and Rolls Royce with their Trent
    engine series--that power major commercial aircraft.
        Perhaps we ought to have them come in and talk with us
    about the adequacy of standards on the fan blades, those
    titanium fan blades. How they get inspections for very small
    imperfections. As little as a millimeter of indentation in the
    fan blade is enough to take it out of service and replace it.
    But what when it entirely disintegrates and when the pieces get
    into the bypass or other portions of the engine? Aircraft
    engines are enormously reliable. If you go to the 1940s, the
    time between overhaul was 300 hours; you get into the 1950s,
    time between overhaul was up to 600 hours; and then with the
    DC-9 it got up to 30,000 hours time between overhaul; and now
    it is up to 50,000 hours. Wonderful, except it can't withstand
    a bird strike. And we are not testing those engines adequately
    at a level to protect life.
        And then we ought to also have both Boeing and Airbus
    report to us on their structural standards for the hull. The
    crew made a very good decision to, in effect, create a tail
    strike on landing and gently get that aircraft into the ground,
    but the hull buckled and water entered the cabin. That is not
    very encouraging when you have to face the prospect of putting
    on a life vest inside the cabin to float and get yourself out.
    There perhaps are some design inadequacies of hull construction
    that we also ought to take a look at.
        So as you pursue this very important inquiry today, and we
    have in the room the Flight Standards Service, we have the
    NTSB, we have Dr. Dillingham from GAO, all of whom are familiar
    with these subject matters--I put them on notice, at your
    direction, we would have a follow-up inquiry on this subject.
        Thank you.
        Mr. Costello. The Chair thanks you and will advise all
    Members that your entire opening statement will be inserted in
    the record. We would ask that you give brief comments.
        Now, the Chair will recognize the gentlelady from Texas,
    Ms. Johnson.
        Ms. Johnson. Thank you very much, Mr. Chairman, and thank
    you for having this important hearing. It is extremely
    important to me, having practices professional nursing for a
    number of years. I can speak firsthand on the importance of
    rendering emergency care within critical time windows
    immediately following a serious accident. And, without
    question, the proliferation of helicopter emergency medical
    services, or HEMS, has proven to be literally vital, important
    lifesaving tool in the preservation of life for countless
    accident victims by ensuring that they are able to receive
    timely medical attention.
        According to the 2005 report by Helicopter Association
    International, in 1991, there were 225 helicopters dedicated to
    air medical service. Today there are approximately 850 in
    service, providing for approximately 81.4 million Americans.
    However, as the data before us may suggest, this proliferation
    has not come without its share of fatal accidents, many of
    which aviation experts indicate could have been prevented.
        Over the past year, accidents involving HEMS has increased
    significantly relative to previous years, and according to the
    data provided by staff, there were 13 HEMS accidents, resulting
    in 35 fatalities between December 2007 and October 2008, and
    that is the most in any 11-month period in history.
        Thank you, Mr. Chairman. I will submit the rest of my
    statement to the record.
        Mr. Costello. The Chair thanks the gentlelady and now
    recognizes the gentleman from Tennessee, Mr. Duncan.
        Mr. Duncan. Thank you very much, Mr. Chairman. I don't have
    a lengthy formal statement, but I do want to first thank you
    and Ranking Member Petri for calling this hearing. I want to
    also commend our colleagues, Congressman Salazar and
    Congressman Altmire, for their interest in this.
        There is great interest in this subject, as I found out,
    because I have been contacted by both the University of
    Tennessee Hospital in Knoxville and the Vanderbilt University
    Hospital in Nashville about this legislation, and I have some
    interest in it that several years ago I introduced the Aviation
    Medical Assistance Act, and we made that a part of one of our
    FAA reauthorizations to increase the medical training for
    airline personnel and to create the first Good Samaritan law in
    the skies to erase any concerns doctors or nurses or others
    might have in rendering assistance during medical emergencies
    in planes. So it is along these same lines that we are dealing
    with, some of these subjects here today.
        I also have come with great interest to welcome back our
    former staffer, the new Acting Assistant Secretary, Ms.
    Fornarotto. I don't want to put any extra pressure on her, but
    I am looking forward to her first testimony before the
    Committee.
        Thank you, Mr. Chairman.
        Mr. Costello. The Chair thanks you and now recognizes the
    gentleman from Michigan, Dr. Ehlers. Then we will go to our
    first witness, Congressman Salazar.
        Mr. Ehlers. Thank you, Mr. Chairman. I will try to be
    brief. I am a proud cosponsor of the Miller-Altmire bill, and I
    think it is needed.
        Michigan has always done pretty well. We have a very
    functional EMS system. The State controls it through a
    Certificate of Need program. We have coverage over the entire
    State, even though much of Michigan is highly rural or even
    less than rural, and the system works well.
        It is ironic that this hearing came now, but we had our
    first accident in a Grand Rapids helicopter this summer.
    Ironically, I was up in the air taking a flying lesson at the
    time and saw this huge plume of black smoke coming up from the
    center of Grand Rapids, so I got on the ground and started
    driving back. Fortunately, there were no patients aboard the
    helicopter; it crashed while landing at the hospital. The only
    other person besides the pilot was an FAA inspector, who was
    forcing the pilot to go through all his procedures and somehow
    a gust of wind caught them and they caught fire.
        Be that as it may, we have a good record in Michigan, and
    we have lots of discussions in the newspapers, both letters to
    the editors and news analysis, about the accident and so forth,
    and recognize no one got killed. They did lose a helicopter,
    but the interesting fact that emerged is that the number of
    fatalities or injuries of patients was much higher in land-
    based ambulances than it was in air ambulances, which indicates
    the very good record that we have in Michigan.
        So I would just urge that we recognize that some States and
    some communities do it right, and let's be careful, as we go
    through this, that we not in some way endanger the operations
    that are already working well, and try to bring all the others
    up to snuff.
        There is absolutely no reason to have a surplus of
    ambulances, these air ambulances. These are very expensive
    machines, very high hourly rate, and that money has to be paid
    somehow. I think if we have too many, then you are really
    boosting the cost of medical care in a way that is not
    necessary.
        With that, I yield back. Thank you.
        Mr. Costello. The Chair thanks the gentleman.
        Now we will go to our first panel, the Honorable John
    Salazar, representing the 3rd District of Colorado. As Chairman
    Oberstar, Congressman Salazar served on this Subcommittee and
    the Full Committee before he moved on to another Committee, but
    we still consider him family and look forward to hearing his
    testimony.
        You are recognized, John.

    STATEMENT OF HON. JOHN T. SALAZAR, A REPRESENTATIVE IN CONGRESS
                       FROM THE STATE OF COLORADO

        Mr. Salazar. Thank you, Mr. Chairman. Chairman Costello,
    Ranking Member Petri, and Members of the Committee, it is an
    honor to be back to my old Subcommittee, one of the greatest
    Subcommittees, I think, in Congress. I want to thank you for
    inviting me today to testify on the topic of air medical
    service, and specifically on the bill that we have introduced,
    H.R. 1201, the Air Medical Safety Act. I also want to commend
    the Chairman, Chairman Costello, for your leadership on this
    issue, and Ranking Member Petri, as well as other Members of
    the Committee.
        I consider H.R. 1201 to be a starting point on this
    critical safety issue. Since its introduction, my staff,
    Cathleen Breslin and members of this Committee's staff as well,
    have worked with the FAA, with the NTSB, with the industry and
    a number of advocacy groups to ensure that this legislation is
    fair, effective, and meaningful.
        We have already made a number of changes, most of them
    technical, but important nonetheless. Among them, changing the
    word pilot to certificate holder and requiring a rulemaking on
    devices that perform the function of recording voice
    communications and flight data information. We are also adding
    terrain and obstacle avoidance systems to the bill, a key
    component to enhance EMS flight safety.
        Before I go further, I would like to recognize Stacey
    Friedman, who will be testifying later. Stacey's sister, Erin
    Reed, was a flight nurse who died in September of 2005 when her
    helicopter lost control in inclement weather conditions after
    delivering a patient to a nearby hospital.
        I would also like to recognize Congressman Dan Lungren, who
    is the cosponsor of this bill with me.
        I think this is a very important piece of legislation. It
    is bipartisan and I can assure you that human safety is not a
    partisan issue. Our bill increases the safety of crew and
    passengers on aircraft providing emergency medical services,
    EMS.
        We have a very important person on this Committee - Jimmy
    Miller, Director of Facilities and Travel, whose life was saved
    because of EMS. A wonderful, great service to this Committee.
    We appreciate that, Jimmy, and I appreciate working with you
    over the last several years.
        Our bill increases the safety of crew and passengers on
    aircraft. Colorado has seen three fatal crashes of EMS flights
    since 2000, and all of those have occurred in my district. The
    most recent one was in Alamosa, which is 30 miles away from my
    home, in October of 2007. The other two crashes were in 2005,
    one based out of Steamboat Springs, Colorado and the other one
    near Mancos, Colorado.
        H.R. 1201 includes recommendations that the National
    Transportation Safety Board made to the FAA in response to
    several air medical crashes to help improve safety. One of the
    issues on their list was the impact of Part 91 of the FAA code.
    This was brought to my attention by St. Mary's Care Flight
    operating out of St. Mary's Hospital and Medical Center in
    Grand Junction, Colorado.
        A great majority of air medical crashes over the past five
    to seven years have been conducted under FAA Part 91
    regulations. As many of you know, Part 91 allows EMS crews to
    fly in conditions which are more dangerous than what is
    permitted when a patient or an organ is onboard. Specifically,
    it allows for much less stringent weather minimums and does not
    restrict pilot duty time, compared to Part 135 of the same
    code. The lives of our pilots and air medical crews should be
    protected by the same weather minimums and pilot duty time
    requirements that these patients are afforded during their leg
    of transport.
        So this bill will eliminate the Part 91 regulations for
    certain flights and direct the FAA to study and implement
    several other proposals to increase safety conditions for
    medical flights. I do credit the FAA for some recent
    advancements in this area, but I still believe that much more
    needs to be done, and in a timely manner.
        In closing, I would like to recognize the efforts of the
    many families who have responded to their losses with
    determination to help others. By increasing safety conditions
    for medical flights, we will not only honor the remarkable
    sacrifices of those who gave their lives while trying to help
    others, but in their honor we will also prevent similar
    tragedies from occurring in the future.
        I want to thank this Committee. I want to thank the
    Chairman and Mr. Petri once again for giving me the opportunity
    to speak with you today.
        Mr. Costello. The Chair thanks you. It has been the
    tradition of this Committee not to ask the Member to wait to
    answer questions. We realize that you have a busy schedule. If
    Members have questions, we will submit them in writing. Again,
    we thank you. We thank you for your legislation, and we look
    forward to working with you to try and come up with legislation
    that is in the best interest and accomplishes what we are
    attempting to do here with this hearing, and what you and Mr.
    Altmire and others are attempting to do with your legislation.
    Thank you.
        Mr. Salazar. I want to thank you, Mr. Chairman.
        Mr. Costello. The Chair would ask the first panel of
    witnesses to come forward. I will introduce them as they are
    taking their seats.
        The Honorable Christa Fornarotto, Acting Assistant
    Secretary of Aviation and International Affairs, with the U.S.
    Department of Transportation; Mr. John Allen, the Director of
    Flight Standards Service, Federal Aviation Administration; the
    Honorable Robert Sumwalt, III, Board Member with the National
    Transportation Safety Board; Dr. Gerald Dillingham, the
    Director of Physical Infrastructure Issues, U.S. Government
    Accountability Office.
        We would ask all of our witnesses to take their seats. In
    the interest of full disclosure, let me say that Ms. Fornarotto
    used to be my legislative director and was a staff member of
    this Subcommittee for a number of years. Mr. Petri and I were
    just talking. He suggested we may want to swear you in, but I
    think we are going to not do that today.
        [Laughter.]
        Mr. Costello. Let me welcome all of you here today on this
    important topic. First, let me say that your full statement
    will be entered into the record, and we would ask that you
    summarize your testimony under the five minute rule.
        The Chair now recognizes Ms. Fornarotto.

    TESTIMONY OF THE HONORABLE CHRISTA FORNAROTTO, ACTING ASSISTANT
        SECRETARY FOR AVIATION AND INTERNATIONAL AFFAIRS, U.S.
      DEPARTMENT OF TRANSPORTATION; JOHN ALLEN, DIRECTOR, FLIGHT
        STANDARDS SERVICE, FEDERAL AVIATION ADMINISTRATION; THE
       HONORABLE ROBERT L. SUMWALT, III, BOARD MEMBER, NATIONAL
        TRANSPORTATION SAFETY BOARD; AND DR. GERALD DILLINGHAM,
       DIRECTOR, PHYSICAL INFRASTRUCTURE ISSUES, U.S. GOVERNMENT
                         ACCOUNTABILITY OFFICE

        Ms. Fornarotto. Mr. Chairman, Mr. Petri, Members of the
    Subcommittee, thank you for inviting me to this hearing. The
    Department of Transportation takes air ambulance services
    issues very seriously, and we appreciate the opportunity to
    testify here today.
        H.R. 978, the Helicopter Medical Services Patient Safety
    Protection and Coordination Act, contains several provisions
    that seek to provide States with additional authority to
    regulate helicopter air ambulances. Under current law, air
    ambulances are air carriers subject to the Airline Deregulation
    Act of 1978. The ADA ended the government's economic control
    over airfares and services, and, instead, relies on competitive
    market forces. As such, States are prohibited from enforcing
    regulations related to air carrier prices, routes, and
    services.
        That said, the ADA has no bearing on a State's ability to
    regulate the medical aspects of air ambulances, including
    patient medical care. It is has long been the Department's view
    that the provision of medical services is not aviation
    services, and, thus, not preempted by the ADA.
        The Department of Transportation has long supported the
    authority of States to issue FAA compliant regulations on
    patient care that would affect air ambulance operations. We
    recognize the interest States have in ensuring that medical
    professionals on board air ambulances are properly qualified
    and that air ambulances arrive properly equipped with the
    medical and communications equipment necessary to care for
    patients and communicate with emergency medical services
    personnel on the ground.
        Although State regulations that would affect air ambulances
    must always be compliant with FAA requirements, we believe that
    there is a wide range of medically related interests that
    States can, and currently do, regulate without encroaching on
    the Department of Transportation's economic authority under the
    ADA.
        We have strong concerns, however, that carving out
    statutory exemptions to the ADA for purposes of allowing States
    to regulate economic issues involving one segment of the
    aviation industry will lead to many of the same problems that
    Congress sought to avoid when it passed the ADA's preemption
    provision over 30 years ago. More specifically, we are
    concerned that the legislation, one, could serve to limit
    market entry and could ultimately have a negative effect on the
    available services, given market access in aviation services
    generally has been instrumental in promoting a safe, efficient,
    and responsive industry; two, potentially would create
    conflicting State rules that may prevent patient transport
    across State lines; and, three, may create a slippery slope for
    the federally regulated aviation industry should Congress set a
    precedent in the area of air ambulances.
        I also note that the bill would distinguish EMS helicopters
    from EMS fixed wing air carriers. While the Department has
    concerns over the legislation generally, we see no appropriate
    basis for making this distinction.
        Given these concerns, we ask that before the Committee
    legislates in the area of economic regulation, that it consider
    carefully whether the troubling stories we have read about are
    relatively isolated incidents or indicative of a larger
    systemic problem. For example, among those testifying before
    you today are two groups representing participants in the air
    ambulance industry. At the Department, we have met with these
    organizations, and what concerns us most is the lack of
    agreement and actual hard data not only on the nature of the
    problems with the existing system, but on whether systemic
    problems exist.
        We recognize that we have had several air ambulance crashes
    in 2008, and these tragedies shine an important spotlight on
    safety within this industry. Some have criticized the
    industry's business structure, but can point to no study or
    recurring evidence that competition has compromised air safety
    and medical care.
        In closing, Mr. Chairman, we look forward to working with
    you, Congressman Altmire, other Members of this Committee, and
    interested stakeholders to address this important aviation
    issue. Thank you for the opportunity to testify today, and I
    would be happy to answer any questions or comments you may
    have.
        Mr. Costello. The Chair thanks you and compliments you on
    your first visit and testimony before this Subcommittee.
        The Chair now recognizes Mr. Allen.
        Mr. Allen. Chairman Costello, Ranking Member Petri, Members
    of the Subcommittee, thank you very much for inviting me here
    today to discuss the safety oversight of helicopter medical
    emergency services, also known as HEMS.
        HEMS operations are a critical aviation service provided to
    the medical community. The medical treatment aspect is
    obviously an essential part of a HEMS operation. However, the
    FAA's mission is to assure the safety of the air transportation
    portion of the operation. The best medical treatment in the
    world won't make a difference if the patient and crew can't be
    transported safely.
        The FAA is taking steps to improve the safety in this
    evolving industry. As always, our goal is to have a zero
    percent accident rate. Unfortunately, there has been a spike in
    the number of fatal HEMS accidents in 2008. From 2002 to 2007,
    there were 26 fatal HEMS accidents, an average of 4.3 accidents
    per year. In 2008 alone there were 8 fatal HEMS accidents.
    These 34 accidents have resulted in 89 fatalities, 71 of whom
    were crew members.
        One of the things that the FAA has identified that can
    improve the safety of HEMS flight is to build a strong safety
    culture in the industry. These operations take place in very
    demanding environments. The pilot's judgment and risk
    assessment is critical in deciding whether an air ambulance
    flight request should be accepted. When weather or other
    conditions put flight delay or cancellations on the table, the
    pilot must have the fortitude to make the call of go or no go.
    The FAA believes that the operator must create a safety culture
    and environment that promotes and supports the safety decisions
    and good judgment exercised by the pilot.
        The FAA has taken several other steps to immediately
    improve HEMS safety while working on a formal rulemaking. In
    2004, we engaged the industry in several voluntary compliance
    measures. In this way, we effect immediate change and see
    safety benefits right away. Our changes have included raising
    the weather minima by operation specification, which we also
    refer to as OPSPEC. These higher weather minima provide better
    visibility conditions for safe flight.
        We have also issued guidance on establishing operational
    control or dispatch systems and risk assessment programs. In
    December 2008, we issued a technical standard for helicopter
    terrain awareness and warning systems, also referred to as
    HTAWS.
        We are pleased that the HEMS industry has been very
    responsive in voluntarily adopting these measures. In January
    2009, the FAA conducted a survey of all HEMS operators. We
    wanted to find out how many have actually implemented FAA-
    recommended best practices. We found the response to be
    overwhelming. Well over 80 percent of the operators have
    established risk assessment programs and operational control
    centers, almost 90 percent are using radar altimeters, while
    just over 40 percent have voluntarily equipped some or all of
    their fleets with HTAWS. We expect this last percentage to rise
    now that the HTAWS technical standards order has been
    published.
        We recognize that relying on voluntary compliance alone is
    not enough to assure safe flight operations, so the FAA has
    initiated a formal rulemaking project that will address many of
    the HEMS initiatives and best practices.
        We appreciate both Congressman Salazar's and Congressman
    Altmire's efforts in the proposed bills to continue to raise
    the bar on HEMS safety; however, the current regulations, the
    industry's voluntary safety efforts, and our rulemaking effort
    already address the safety issues in H.R. 1201.
        The FAA also appreciates that the intent of H.R. 978 is not
    to infringe upon the FAA's safety authority or for civil
    aviation. And, in order to ensure that there are no unintended
    consequences of either bill that might adversely affect HEMS
    safety, the FAA stands ready to work with this Committee to
    address any safety concerns.
        Mr. Chairman, Congressman Petri, Members of the
    Subcommittee, this concludes my prepared remarks. I am happy to
    answer any questions you may have.
        Mr. Costello. The Chair thanks you and now recognizes Mr.
    Sumwalt.
        Mr. Sumwalt. Good morning, Chairman Costello, Ranking
    Member Petri, and Members of the Subcommittee. Thank you for
    the opportunity to present testimony on behalf of the National
    Transportation Safety Board.
        I would like to give you a short summary of the Safety
    Board's activities regarding the safety of helicopter EMS
    operations, or HEMS.
        The HEMS industry provides an extremely important service
    by transporting seriously ill patients and donor organs to
    emergency care facilities. Indeed, they are credited with
    saving countless lives each year. That said, the recent
    accident record is alarming, and it is unacceptable. In the
    past six years, there have been 84 HEMS accidents resulting in
    77 fatalities and last year alone was the most deadly year on
    record for medical helicopters.
        The Safety Board has had a longstanding interest in EMS
    aviation. For example, in 1988, the Board conducted a safety
    study of commercial EMS helicopter operations. That study
    evaluated 59 EMS helicopter accidents and resulted in the
    Safety Board issuing 19 safety recommendations.
        Prompted by a recent rise in EMS accidents, in January of
    2006, the Safety Board adopted a special investigation report
    EMS operations. That special investigation analyzed 55 EMS
    accidents that occurred in a three-year period, and claimed 54
    lives. As a result of that special investigation, the Safety
    Board issued four recommendations to the FAA to improve safety
    of these operations. Of significance, the Safety Board
    determined that 29 of the 55 accidents could have been
    prevented if the corrective actions in the report had been
    implemented.
        These safety recommendations called on the FAA to require
    all EMS flights, even those without passengers onboard, to be
    conducted in accordance with FAR Part 135 on demand charter
    regulations; to develop and implement flight risk evaluation
    programs; to require formalized flight dispatch and flight
    following programs, including up-to-date weather information;
    and install terrain awareness and warning systems, or TAWS, on
    aircraft.
        These recommendations were added to the Safety Board's Most
    Wanted List of Transportation Safety Improvements in October of
    2008, and the decision to place these recommendations on the
    Safety Board's Most Wanted List was prompted by two primary
    reasons: one, the FAA's lack of timely action on the
    recommendations and, two, the appalling number of helicopter
    EMS accidents. Currently, three of the four recommendations on
    this list are classified by the Board as ``Open, Unacceptable
    Response.''
        The Safety Board is concerned that these types of accidents
    will continue if a concerted effort is not made to improve the
    safety of emergency medical flights.
        In February of this year, the Safety Board held a four-day
    public hearing on HEMS, making it one of the longest NTSB
    public hearings on record, and I was privileged and honored to
    serve as chairman of the Board of Inquiry for that public
    hearing. The hearing took a comprehensive look at the HEMS
    industry. We looked at business models, the growth in the
    industry, and competition; we examined flight operations
    procedures, including flight planning, weather minimums, and
    pre-flight risk assessment; we discussed safety enhancing
    technologies such as terrain awareness and warning systems
    (TAWS) and night vision imaging system (NVIS); training,
    including the use of flight simulators, was discussed; and we
    probed the corporate and government oversight of the HEMS
    industry.
        Possible courses of action that could result from this
    hearing are numerous, including an updated safety study on EMS
    operations and additional safety recommendations. The NTSB
    staff are currently examining the information obtained from the
    public hearing, which totals over 3,000 pages of documents.
    Whatever we do, the Safety Board's motivation is simple: to
    find innovative ways to improve helicopter EMS safety.
        I am very pleased to hear this morning that the FAA has
    announced a rulemaking initiative, and the Safety Board looks
    forward to following the progress of this rulemaking effort.
        Mr. Chairman, this concludes my testimony, and I would be
    glad to answer questions at the appropriate time.
        Mr. Costello. The Chair thanks you and now recognizes Dr.
    Dillingham.
        Mr. Dillingham. Good morning, Chairman Costello, Mr. Petri,
    Members of the Subcommittee.
        Thanks to the FAA, the wider aviation community, and
    congressional oversight, U.S. aviation has one of the safest
    records in the world. However, there are segments of the
    aviation community that have not achieved the same high level
    of safety, and their records remain a significant concern.
        In line with both Mr. Sumwalt's testimony and the consensus
    of opinion from the NTSB's February 2009 conference, as well as
    the statements by Mr. Mica this morning, the industry's recent
    accident record is simply unacceptable. Between 1998 and 2008,
    there were roughly 146 air ambulance accidents in the United
    States, 48 of which resulted in the deaths of over 125 people.
    This means that the industry averaged 13 accidents and 12
    fatalities per year during that time period.
        In 2008, the number of fatalities increased sharply to 29.
    Because the industry grew substantially during that period, and
    because FAA does not systematically collect and analyze data on
    air ambulance operations, we can't really be sure what these
    numbers mean in terms of the industry's accident rate.
    Nevertheless, the overall number of accidents and the spike in
    the number of fatal accidents in 2008 are causes for concern.
        Our analysis of the data on air ambulance accidents showed
    that pilot error was the probable cause of 70 percent of the
    accidents that occurred during the last decade. Additionally,
    flight environmental factors, such as nighttime flying, adverse
    weather, and flight into terrain contributed to 54 percent of
    these accidents. In some locales, competition has increased
    with a growth in the number of standalone air ambulance service
    providers and changes in the Medicare reimbursement rules.
        Some experts say that competition has led to potentially
    unsafe practices, such as helicopter shopping. NTSB's aviation
    accident database does indicate that crashes have occurred
    after pilots have taken risky action, such as accepting flights
    after another pilot refused to fly because of bad weather.
        In response to the increased number of accidents, NTSB made
    four significant recommendations in 2006, and FAA and the
    industry have also implemented a wide range of initiatives to
    improve safety. As Mr. Sumwalt testified, despite these
    initiatives, 2008 was the deadliest year on record for the air
    ambulance industry.
        Additional efforts are clearly warranted. The question is
    where do we need to go from here. We have identified several
    strategies with the potential to improve air ambulance safety.
    First, FAA and the industry must sustain their current focus on
    safety improvements. The pattern of events that we are seeing
    now is a pattern that we have seen before. In the mid-1980s,
    after a significant increase in the number of air ambulance
    accidents, subsequent media and congressional attention, NTSB
    recommendations and FAA actions, the number of air ambulance
    accidents declined. But as time passed and attention waned, the
    number of accidents started to increase, peaking in 2003. We
    found a similar pattern in our work on runway incursions for
    this Subcommittee.
        FAA has taken a positive step towards sustaining its focus
    on safety by announcing the start of a rulemaking that will
    address NTSB's 2006 recommendations. It is important to note
    that sustaining current efforts is critical, because it may be
    many years before any new regulations are completed and
    implemented by FAA.
        A second strategy is for FAA to obtain complete and
    accurate data on air ambulance operations. FAA needs such data
    to better understand the industry's safety record and determine
    whether its own efforts to improve air ambulance safety are
    accurately targeted and sufficient.
        A third strategy would involve FAA encouraging the
    transformation of the air ambulance industry so that operators
    would establish a corporate culture based on safety and adopt
    tools, such as safety management systems.
        A final strategy would use empirical analysis to address
    the risk profile of the industry and to help resolve national
    issues, such as the role of States in overseeing ambulance
    services, the impact of Medicare reimbursement on usage, and
    the appropriate use of air ambulance services.
        Mr. Chairman, that concludes my statement. Thank you.
        Mr. Costello. Dr. Dillingham, thank you.
        Mr. Allen, you heard Mr. Sumwalt's testimony, and I will
    read it back to you, a part of a statement that he has made in
    his testimony. He says the 2006 special investigation resulted
    in the Safety Board issuing four recommendations to the FAA to
    improve the safety of these operations. Of significance, the
    Board determined that 29, 29 of the 55 reviewed accidents could
    have been prevented if the corrective action recommended in the
    report had been implemented.
        Do you agree with that statement?
        Mr. Allen. Well, sir, it is a hypothetical situation as to
    whether those accidents would have actually been prevented if
    those had been implemented. It is understandable that those, if
    implemented, would raise the safety bar, and, obviously, we
    have been working very, very hard with the industry to
    voluntarily comply with many of the NTSB safety
    recommendations. It is a question as to how many accidents we
    also prevented with the voluntary application of those
    initiatives, and we think that there has been a great benefit
    to safety with those voluntary applications.
        But to understand whether some would have actually been
    prevented, there are also other certificate holders out there
    who are very fastidious in their application of the regulations
    and of many safety initiatives, that have never had an
    accident. So I do think, obviously, sir, that the industry is
    not wrong and that they would have definitely helped the
    prevention of an accident, but I can't say unequivocally that
    they would have actually prevented any one of those actual
    accidents.
        Mr. Costello. I wonder if you might follow up on the
    statement that you made, Mr. Sumwalt, that the 29 of the 55
    reviewed accidents could have been prevented.
        Mr. Sumwalt. That is right, Mr. Chairman. In the special
    investigation report, we looked at what intervention measures
    hypothetically could have prevented those accidents. For
    example, if we saw a controlled flight into terrain (CFIT)
    accident, we would say what could have prevented that, and the
    answer to that would be the application of a terrain awareness
    and warning system, or TAWS. So, therefore, when we saw the 16
    or so see-fit accidents in the report, we would say, well, the
    TAWS could have prevented those. We did that for each of the
    intervention strategies that we had outlined.
        Mr. Costello. Dr. Dillingham, you heard Mr. Allen refer to
    voluntary compliance. Is that good enough, relying on voluntary
    compliance by the industry? Is that adequate or should the FAA
    be taking a different approach?
        Mr. Dillingham. Mr. Chairman, we think that the voluntary
    compliance was a first step, but it clearly is not enough. I
    mean, voluntary compliance is--and we agree with the FAA in the
    sense that it is easier, quicker to develop voluntary kinds of
    compliance while, in the meantime, working on regulatory
    issues, such as FAA has just announced that they are in fact
    developing rules.
        The other point that we want to make is that FAA indicates
    that they have checked with the industry in terms of the extent
    to which they are actually complying with these voluntary
    rules. We have some concerns about how valid that information
    is that they are getting, because to the extent that it is
    based on data that are collected from less than half the
    industry, we don't put too much credit in the validity of that
    information.
        Mr. Costello. Before I go to other Members to ask
    questions, let me just ask you to summarize very quickly what
    is it that the FAA needs to do to address this problem. Dr.
    Dillingham.
        Mr. Dillingham. I think the first thing they need to do is
    sustain the actions that they are doing now until the
    regulations are enforced. I think they need to collect the
    information so that they can monitor the effect of what they
    are doing, and they need to further push the use of
    technologies such as the TAWS that Mr. Sumwalt mentioned.
        Mr. Costello. Mr. Sumwalt, from your perspective, from the
    NTSB's, what should the FAA be doing?
        Mr. Sumwalt. From our perspective, Mr. Chairman, we would
    like to see the FAA implement the rulemaking on the four
    recommendations that we have issued. We understand from this
    morning that some regulatory action is beginning, but we, of
    course, would like to see that rulemaking completed.
        Mr. Costello. We all recognize how long rulemaking takes.
    It takes a significant time. But I will come back; I have some
    other questions and comments.
        The Chair now recognizes the Ranking Member of the
    Subcommittee, Mr. Petri.
        Mr. Petri. Thank you very much, Mr. Chairman. I have
    several questions for Ms. Fornarotto and Mr. Allen, who
    submitted a joint statement, and we will leave it up to you to
    either both respond or whoever would like to respond.
        There seems to be, in some of the statements that were
    submitted, some confusion as to exactly what authority States
    have to regulate medical portions of emergency medical services
    flights. Could you clarify what the agency's position is as to
    where the line is between what is within States' authority to
    regulate and what would be preempted by the Airline
    Deregulation Act?
        Ms. Fornarotto. Sure. As I said in my opening statement, we
    make a strong distinction at the Department between aviation
    services and medical services, and we do believe that, under
    ADA, we reserve the right to regulate on aviation services, but
    States have the right to regulate on medical services. That is
    the distinction that we make.
        Mr. Petri. But sometimes it requires a modification of the
    aircraft to put in a medical device or sometimes there are
    questions--I know we had met with some people that were talking
    about temperatures in the craft and equipment to achieve that
    temperature, and whether you can mandate the temperature or
    just mandate the equipment. It is not as automatic a line when
    you actually come down to apply it, it does require some give
    and take and negotiation, or at least some clarification so
    that States don't end up with requirements to comply with which
    a plane couldn't necessarily go to another State.
        Mr. Allen. Yes, sir. The interfaces, as I call it, between
    the medical community and the aviation community are a very key
    piece to understanding this whole safety equation. But when it
    comes to aviation safety, we affirm that we have responsibility
    and authority to have the last call and to have the definitive
    statement on what is correct and not correct. That is why we
    have been working very closely with Congressman Altmire's
    staff, to make sure that there isn't any overlap there and that
    there is a clear distinction that the States can have free rein
    on regulating their health portion of the operation, but when
    it comes to aviation safety, the Federal Aviation
    Administration have the authority and responsibility of safety
    oversight.
        Many of these HEMS operators are interstate versus
    intrastate, so, therefore, it is important that we have the
    purview of safety oversight for them.
        Mr. Petri. Now, you indicated that there is a lack of
    agreement not only on the nature of the problem with the
    existing helicopter emergency medical system, but whether any
    serious problem exists at all with regard to issues surrounding
    H.R. 978. Could you elaborate on that? Are you sure the medical
    air transportation system is broken, as some have claimed?
    Would there be a need for a study in this area, and would you
    support such a study?
        Ms. Fornarotto. We would. We do believe that clarification
    needs to be made. You are going to hear today, we have heard it
    at the agency, that there are varying stories on what is going
    on in the field, and in order to get clarification on that, in
    order to get a better understanding of what is going on so as
    to get to the bottom of these issues, we do believe that a
    comprehensive study would be very helpful in sorting out what
    is going on. So before we actually propose a solution, let's
    actually figure out what the problem is first.
        Mr. Petri. One final question. I suppose it is obvious, but
    maybe you could state how are helicopters different from
    ambulances in the air. Why should they be treated differently
    from ground ambulance services by the regulators?
        Ms. Fornarotto. From an economic side, we look at it in
    terms of interstate operations. These operators, they file for
    interstate operation certification, and the ADA was very
    specific in making sure that air carrier operations were
    allowed to fly interstate, and that is where we come at it,
    from the interstate perspective.
        Mr. Allen. And, sir, obviously from the safety perspective,
    it is a very difficult environment to operate in. Low weather
    situations sometimes, obstructions on landing zones. You have
    the fusion of human factors and technology and environmental
    conditions that create quite a safety challenge. So, therefore,
    we have--and I don't have any responsibility over the ground
    ambulance infrastructure, but over the aviation side we have to
    put forth a lot of safety initiatives to adequately ensure that
    the safety is at the highest level of this very complex
    environment.
        Mr. Petri. Thank you. Just one real quick add-on. This is a
    unique aviation area, but there are other unique aviation
    areas, people providing specialized services of one kind or
    another. How real is the concern that if there is a kind of a
    carve out or greater State authority in this area, that that
    will create problems in other aviation areas? Do you have any
    view on that or do you think it is unique enough that, if we
    get into this and restrict your authority and enlarge the
    States' authority, that that will be the end of the matter?
        Ms. Fornarotto. Right now, with the ADA, there are no carve
    outs. By going down this road, you are setting up to produce
    one carve out, and it is unclear to us if other unique
    operations, you know, unique, however you define that, would
    also seek a carve out from Congress on that. You know, another
    example of an air taxi would be scenic tours that fly around
    like at the Grand Canyon or in other places. They are a unique
    set of operations and they have high startup costs and other
    things about which you can make similar arguments, and we are
    very concerned about heading down this road and creating a
    slippery slope effect.
        Mr. Costello. The Chair recognizes the gentleman from
    Pennsylvania, Mr. Altmire.
        Mr. Altmire. Thank you, Chairman Costello. I want to ask a
    couple of questions for Ms. Fornarotto.
        Thank you for being here. And I do appreciate the
    assistance that everyone involved has given to our office in
    helping to work through some of these issues on which we
    clearly differ on some, but we are working through it.
        I have the same general question in response to your
    testimony. You indicated that the Department of Transportation
    says that States should not regulate the economics involved,
    and ADA exempts States, but I want to know what is the role of
    the Department of Transportation in actually doing that
    regulation? Because if it is not being done at the ADA, has the
    DOT issued regulations? Is there something that has been
    formally done?
        Ms. Fornarotto. So Congress passes a law and then one of
    the roles of the agency is to enforce the laws, the statutes,
    and we do do regulations based on that. And one of the things
    we do--and I know that you have seen these--is we do guidance
    letters, and if a State comes to us with issues or concerns and
    they seek guidance on something specific, we will lay out from
    our perspective what guidance we can provide.
        Mr. Altmire. I appreciate that. You have also indicated
    that the Department of Transportation has said that States can
    regulate staffing of medical personnel, medical equipment,
    sanitation issues. But the DOT has also said, in a letter
    specifically to Hawaii, that criteria related to quality,
    availability, accessibility, and acceptability are specifically
    preempted. So my question is how can a State assure that the
    accountability of the EMS system is in place if it can't
    regulate these specific aspects of helicopter medical services?
        Ms. Fornarotto. One of the things we are seeing as we go
    forward with this and on issues being raised is that each
    instance is very unique, and a lot of these are done on a case-
    by-case basis. That is why we encourage States to contact DOT
    in order to get further guidance, so we can work with them, we
    can talk to them about their issues and be partners in going
    forward.
        Mr. Altmire. So is it your view that States should be able
    to oversee only the medical care and equipment provided inside
    the helicopter, or should they, instead, be able to oversee the
    provision of HMS services, which would include coordination,
    location, and availability of services as well?
        Ms. Fornarotto. Each is done on a case-by-case basis, and I
    want to refrain from trying to say this does fall under the ADA
    or this does not fall under the ADA. Everything is very case
    specific and we do have to look at the totality of whatever a
    State is proposing before we do make a determination.
        Mr. Altmire. Thank you. One last question. In your opinion,
    should medical helicopter providers be required to pick up all
    patients from scenes, even if they are uninsured? And do you
    see a legitimate public interest in such things as requiring
    24/7 availability of HMS providers? And I ask because since
    both of these have been found to be preempted by DOT and DOT
    isn't requiring them, then how else can we ensure that patients
    receive air medical transport when they need it as part of the
    EMS system if States can't set these requirements specifically?
        Ms. Fornarotto. So currently under the ADA, things like 24/
    7, which you raised, geographic restrictions, things like that,
    the ADA preempts. A State can, if they so choose, contract out
    those services. If they truly believe that 24/7 is critical, if
    serving a specific geographic area is critical, a State can
    contract that out.
        You are raising a very important question here, and that is
    there a unique situation with the air ambulance services, and
    from DOT's perspective we are saying let's study this further.
    Let's get some more information. Let's see what is going on
    before we actually legislate on this, carve-out could have
    unintended consequences down the road.
        Mr. Altmire. Thank you.
        One very quick point for Mr. Allen. I just want to say
    publicly how much I appreciate FAA's thoughtful comments on how
    we can improve H.R. 978 to ensure one system is safely governed
    exclusively by FAA while still ensuring that States can
    regulate patient safety and coordination. I am in agreement
    with most of your suggested changes, and I hope that we can
    secure your commitment here today, and it sounds like we have
    it, that we are going to continue to work through the remaining
    issues.
        Mr. Allen. Yes, sir, you have it, and thank you for your
    interest in safety. I appreciate that.
        Mr. Altmire. Thank you.
        Thanks to all of you and thank you, Mr. Chairman.
        Mr. Costello. The Chair thanks the gentleman from
    Pennsylvania and now recognizes the gentlelady from Oklahoma,
    Ms. Fallin.
        Ms. Fallin. Thank you, Mr. Chairman.
        Thank you all for coming today to present such valuable
    information to help keep our airways safe and our patients
    safe. We appreciate all that you do and your thoughtfulness in
    giving us testimony today.
        I had a couple of questions. One is to Mr. Allen. In your
    written statement, it points to a number of voluntary
    compliance measures that have been put in place by the FAA that
    will address the safety issues and rulemaking later this year.
    What issues specifically is the FAA going to address in the
    rulemaking?
        Mr. Allen. Good question, ma'am. Thank you. Actually, many
    of the things that we have already implemented on a voluntary
    basis, but I will go through a quick list of things that we
    intend to put into the rulemaking. First and foremost, and I
    know will make Mr. Sumwalt very happy, is HTAWS, the Helicopter
    Terrain Awareness Warning System, that I said 40 percent of the
    industry have already implemented voluntarily, 41 percent,
    actually. The use of radar altimeters. For those operators that
    have 10 or more aircraft, to have an operational control
    center, dispatch center. To put in the rulemaking what we are
    already prescribing under operational specification, that is,
    the use of Part 135 weather minima for all legs of an air
    transport operation. Implementation of risk management
    programs. To require flight data monitoring devices on the
    aircraft. We call them cockpit voice recorders and digital
    flight recorders. And also inadvertent IMC, meaning weather
    recovery demonstration, brownout, whiteout, flatout lighting.
    We found that many accidents are attributed to inadvertent
    entry into weather situations that the pilots weren't
    appropriately trained on, so that would be required in the
    regulation. And we have some other things that are more of a
    detailed nature in terms of the training of passengers and also
    better definition of what HEMS operators can do in terms of an
    approach if weather is at low minimums.
        Those are the primary aspects of the regulation, and there
    will be other things that we will most likely consider as we go
    out for comment and receive those comments.
        Ms. Fallin. So let me ask a follow-up question. Do you
    think that we need safety legislation or do you think you can
    implement these things through the rulemaking?
        Mr. Allen. Well, we are always very, very appreciative of
    the assistance by Congress in the realm of safety, so we
    believe that some aspects of legislation--Congressman Salazar's
    bill, I believe we accommodate all of his issues, but if they
    work together, then I think it buttresses the safety issue. So
    we look, as we have said, to working with them to make sure
    that they work in a conjoined path. So I don't think that they
    hurt one another; I think that they help one another.
        Ms. Fallin. Okay. I also wanted to ask a question about
    some of the proposals as far as the night vision goggles and
    things like that. How do you anticipate that some of the rural
    communities that use these services and some of the rural
    hospitals that might use ambulance services, how do you
    anticipate they are going to pay for these extra expenses on
    various mandates? I understand what you are trying to do, but I
    am concerned about access to the care, especially for some of
    the communities and some of the hospitals that may not be able
    to afford, and even some of the helicopter companies that may
    not be able to afford some of these changes.
        Mr. Allen. Yes, ma'am. We share your concern, and that is
    part of the reason why we are not requiring implementation of
    night vision goggle systems. We have that as a voluntary
    measure. There is a technical standard out there for the
    implementation. We have wide voluntary application of that
    technology. All the major HEMS operators already voluntarily
    use them. In addition, we found, though, that we wanted to be
    careful of just overly being prescriptive, because some
    operators are not pre-dispositioned to use them. It takes quite
    a bit of training and a change in their helicopter
    infrastructure, so that is quite a transformation, actually, of
    not only equipage, but also how you fly the helicopter. So,
    therefore, we feel that that technology, as valuable as it is,
    and there are a lot of voluntary initiatives to implement
    those, we don't want to be prescriptive on that technology.
    With this rulemaking, we will be prescriptive of HTAWS, but we
    believe that it is a well vetted and analyzed technology that I
    believe is so important that I believe it will be worthwhile
    for all operators to employ.
        Ms. Fallin. Mr. Sumwalt, how do you feel about that, as far
    as requirements on those goggles?
        Mr. Sumwalt. Congresswoman, we do not have a specific
    recommendation at the NTSB regarding the night vision imaging
    systems. At our public hearing in February, we received a good
    bit of testimony on that, and some of the testimony indicated,
    as Mr. Allen said, that night vision imaging systems can be
    very helpful but should not necessarily be applied for all
    operators. So that is one of the things that we are looking at
    as we go through the testimony. We have not issued
    recommendations directly on that.
        Ms. Fallin. I appreciate all your testimony. If I could
    just get a real short answer on what is the training that is
    required to be able to use that? I assume that you have to go
    through some specific training to know how to use the goggles.
    How much time or course work?
        Mr. Sumwalt. I am not a subject matter expert; I will let
    Mr. Allen answer.
        Mr. Allen. I have to admit, ma'am, I am not a user of the
    night vision goggles, but from those that I work with and work
    for me, it is a bit of a training requirement to understand how
    you would transition, say, from instrument conditions to visual
    conditions; how to train against what we call a brownout or
    whiteout or lights flashing. Now, the technology is getting
    better and those issues aren't as tough to solve as they were
    in the past, but there is a reasonable substantial human
    factors training requirement for that.
        Ms. Fallin. Okay.
        Mr. Sumwalt. I believe it is about a week. I was at Bell
    Helicopter in November, and it was about a week long ground
    school, with some flying as well.
        Ms. Fallin. Okay. Well, that is better than I thought.
    Thank you.
        Mr. Costello. The Chair thanks the gentlelady and now
    recognizes the gentlelady from Hawaii, Mrs. Hirono.
        Mrs. Hirono. Thank you very much, Mr. Chair.
        I know that we are all on the same page in wanting to make
    sure that safety is the first issue that we have to address.
    There has been testimony that indicates that, as to the number
    of accidents, we are not entirely sure what those accident
    numbers mean. However, we do look to NTSB as the entity that
    will investigate aviation accidents. Therefore, the
    recommendations of NTSB are recommendations that I take
    strongly to heart. I know that you are familiar, Ms. Fornarotto
    and Mr. Allen, with NTSB's four recommendations. Mr. Allen, I
    believe you said that the rulemaking that you are undertaking
    addresses these four recommendations. So my question would be
    where are you in the rulemaking process with regard to
    implementing these four recommendations.
        Mr. Allen. Yes, ma'am. We just initiated, we just were able
    to sign off on a rulemaking initiative, and, to be honest with
    you, the culmination of that rulemaking process will probably
    come to fruition by 2011 for the rule to actually be codified
    and be implemented. 2011.
        Mrs. Hirono. Here we are 2009. Based on the testimony, it
    seems to me that one of these bills, which mainly incorporates
    the recommendations of NTSB, which is H.R. 1201, we know that
    rulemaking takes time, and there are reasons that it takes
    time, but would there be any harm, truly, in passing this
    legislation that at least lays a foundation? The indication
    also is, from GAO's testimony, that one of these
    recommendations has already pretty much been implemented. So
    why don't we push ahead, knowing that the safety of the users
    of HEMS is primary? Why not just push ahead with this
    legislation?
        Mr. Allen. I have no argument, ma'am, with this. We look
    forward, as I said, to having all the support that I can get in
    helping safety.
        Mrs. Hirono. Thank you.
        Thank you, Mr. Chairman.
        Mr. Costello. The Chair thanks the gentlelady and now
    recognizes the gentleman from Ohio, Mr. Boccieri.
        Mr. Boccieri. Thank you, Mr. Chairman.
        And thank you to the panel for establishing a discussion on
    this very important legislation. I, at my Air Force Reserve
    base, we fly with pilots who also fly with medical emergency
    system here and then fly into Mr. Altmire's district and bring
    patients. After conversing with them on a number of occasions,
    especially surrounding some of the accidents that have
    occurred, it seems to me that there is a willingness, if not a
    sense of urgency, by the pilots to do all that they can to get
    to that medical emergency and try to save the life of that
    person. So I know that many of the accidents and the
    information that you have suggested it is pilot error, flying
    controlled flight into terrain, but there is a sense of
    urgency, and I would hope that the FAA, in recognizing the
    importance of this legislation and developing the flight risk
    evaluation program, that you will take into consideration that
    sense of urgency that these pilots have to get to that
    emergency.
        A question. First of all a comment. Congresswoman Fallin
    from Oklahoma suggested about the type of training that is
    involved with night vision goggles. Being very proficient in
    this, we have to go through exhaustive training, working with
    crew resource management, working with our crew members to have
    semi-annual requirements, as well as quarterly requirements to
    meet the training requirements of the Air Force, which I am
    certain that you will apply some sort of military connection to
    the training that you have, since they are widely operational
    use by the military, and especially our Air Force and DOD
    helicopter pilots.
        My question to you, Mr. Allen, is you said in your
    testimony that the impact of a positive safety culture on
    operational safety must be recognized by the entire HEMS
    industry. I hope that you will take into account my
    perspective, and I ask you is there any technology out there
    that is being experimented on that allows for a vertical
    instrument landing system, where the folks can hover down to
    the emergency spot? I know that the military employs like
    microwave landing systems, portable instrument landing systems.
    Is there any of that type of technology on the forefront?
        Mr. Allen. That is technology that we are assessing, but we
    have not assessed it in terms of application to the HEMS
    industry. We have looked at it in other facets of the aviation
    industry. We are looking at all types of new technologies and
    their application. Actually, a lot of them come to us from
    industry who would like to employ them, and we look at them,
    analyze them, and look at their application to the industry.
    But, to my knowledge, at this point, we haven't looked at
    microwave landing systems, the vertical descent systems, but
    those are something that obviously we will take a look.
        Mr. Boccieri. Thank you. How soon do you think that this
    technology can be employed or will be employed once you
    evaluate your program? Is it something that can be online
    relatively quickly?
        Mr. Allen. Any new technology takes quite a bit of vetting.
    HTAWS, for instance, took several years because of a new
    application of a technology that I have also used in the
    Reserves, TAWS, had to be reassessed and new standard produced
    for application in this new environment. So it does take quite
    a bit of time to get a consensus, to get the standards defined,
    and then to get them implemented. So I can tell you, as I share
    Congressman Costello's concern about the length of time for
    rulemaking, also, application of new technologies has to go
    through due diligence. So I cannot promise you that it would
    happen overnight.
        Mr. Boccieri. Thank you, Mr. Chairman.
        Mr. Costello. The Chair thanks the gentleman from Ohio and
    now recognizes the gentleman from Boston, Mr. Capuano.
        Mr. Capuano. Thank you, Mr. Chairman.
        Ms. Fornarotto, I have 45 very difficult questions for you,
    but Mr. Costello won't let me ask them. I really don't have too
    many questions. I actually appreciate the fact that you are all
    working on this and trying to work this out. The Committee has
    talked about this in the past and it is an issue that is
    obviously very important to all of us, me included. We all have
    med flights of some sort that work, and I understand the
    difficulties.
        But I also want to be clear that I have yet to find any
    regulator in any business who doesn't over-regulate, doesn't
    have a tendency to do so, I should say. For instance, there
    isn't a single firefighter in Boston who would let anyone in
    Boston ever park a car on the street, because it might get in
    the way of a fire truck somewhere along the line. Of course
    there are rules and regulations about within certain feet of
    the intersection, and those are all reasonable.
        What I am trying to say is, as you go about this, please
    try to be reasonable. Please try to realize it could be your
    family members on that med flight that you need to get to a
    hospital, and it is not just a regular flight. This is not U.S.
    Air bringing me home. This is an emergency situation with a
    loved person on that helicopter that needs emergency medical
    response.
        So as you go about this, I am begging you all--I am not
    suggesting you take your hats off as aviation safety people. I
    am simply saying that you understand this is unique. This is
    not a private enterprise, per se. And the slippery slope
    doesn't bother me on this one. This is a serious and
    unequivocal potential exception to any rules you might have,
    and I am begging you all to look at it that way; not just
    through the prisms that you have all looked at what you do. You
    all do a good job. I feel very safe in the skies. I know the
    NTSB does a great job reviewing every accident that I have ever
    seen. You do a fantastic job. But I am just simply saying
    please, as you look at this, understand this is a unique and
    special situation that does demand your attention, more than
    just air safety professionals.
        I also understand very clearly--and, again, I am not
    pushing them today because I do think it is fair to ask for
    time, but some of the things that concern me. Different States
    do have different levels of interest in medical care. In
    Massachusetts, we don't ask people, when they come in to the
    emergency room, whether they have insurance. Now, I understand
    that is a State law, that is not a Federal law; it is the way
    we like to do things. We don't want to deny anyone health care.
    I would also say the same thing about a med flight. I wouldn't
    want a helicopter service saying, well, what kind of insurance
    do they have. And, again, if a State wants to regulate that, I
    don't see that as an FAA or a safety issue; it is a health care
    issue that has nothing to do with it. An ambulance service in
    Massachusetts is required to provide 24/7 coverage. The last
    thing in the world, if your loved one is sitting in a car wreck
    or has a heart attack in the middle of nowhere, or whatever it
    might be, you don't want to hear, well, we are sorry, yes, we
    do this, but we are not doing it right now. Again, if an air
    carrier wants to stop flying at 9:00 at night, so be it; that
    is life. I have got to wait until the next morning. I don't
    want to hear that for my mother or my child, and I don't think
    any of you would either.
        So there are many things that I simply want to say now, in
    public, that, as you go about this, please, please recognize
    there are things. This is not a commercial air flight. And as
    far as competition goes, I am all for competition. At the same
    time, that competition has to be on the basis of what is fair
    and equal for competition, number one; and, number two, for, in
    this case, health care as well. For instance, I don't know the
    answer, I am not even looking for an answer right now, but as
    we go forward, if, for the sake of discussion, XYZ air carrier
    decides to get into this, will they be treated the same as if
    the St. Elsewhere Hospital decides to have their own med
    flight? And the answer should be yes. I can't imagine they
    wouldn't be. And I understand that different forms of business
    might be seen differently, but, again, in this case, it is an
    exception to the rule. St. Elsewhere wouldn't be carrying--
    actually, if they wanted to get into the airline industry and
    bring me home every other week, then they should be subject to
    the same regulations. But if the air carriers are going to get
    into competition, then the competition should be fair and
    equitable as well, on as many planes as you can get.
        Again, I understand fully well that you are all working
    towards this, and I think it is fair and reasonable that you be
    given an opportunity to come up with regulations, let people be
    heard on them, but as you do, I just want to reemphasize that
    you do this knowing that this is potentially a serious
    exception to the generic rules that you would normally operate
    under. Thank you very much.
        Mr. Costello. The Chair thanks the gentleman and now
    recognizes the gentlelady from California, Ms. Richardson.
        Ms. Richardson. Thank you, Mr. Chairman.
        Two questions. First of all, in the next panel that is
    coming forward, according to Ms. Friedman's testimony, the
    States, the NTSB's 2006 study found that 55 accidents that it
    studied, none of the operators involved required a completion
    of a standardized flight risk evaluation prior to flying. Is
    that your understanding as being correct?
        Mr. Sumwalt. Who is the question directed to?
        Ms. Richardson. Probably, first of all, to our Acting----
        Mr. Allen. Well, actually, ma'am, maybe it is more toward
    on the safety side, I believe it is correct. I don't have the
    stats in front of me, but we did find, when we did the survey
    of our operators, that there was a risk assessment program that
    was accommodated by 94 percent of the HEMS community. I don't
    know if that answers your question, but I believe it does.
        Ms. Richardson. No. Specifically, my question is, according
    to the NTSB study, it found that out of the 55 accidents that
    it studied, none of the operators involved were required to
    complete a standardized flight risk evaluation. Is that true or
    is that not true, or do you know or do you not know?
        Mr. Sumwalt. Well, I will answer that. I am from the NTSB
    and that is a factual statement.
        Ms. Richardson. Okay. Do you see that as being a problem?
        Mr. Sumwalt. Absolutely, and that is why we issued a
    recommendation to require flight risk evaluation. We found that
    of the 55 accidents that we evaluated, 14 of them, we feel,
    could have been prevented if a flight risk evaluation had been
    performed. Furthermore, as you indicated, none of the 55
    flights that we looked at had that flight risk evaluation,
    which indicates that, at the time of these accidents, there was
    not a lot of compliance with using that recommendation. So we
    do feel very strongly that flight risk evaluations should be
    required.
        Ms. Richardson. Mr. Allen, is there any reason why we
    wouldn't implement this now, instead of waiting until the end
    of 2009, in 2010?
        Mr. Allen. Well, yes, ma'am. Actually----
        Ms. Richardson. It seems to be a pretty obvious problem.
        Mr. Allen. Yes, ma'am, it is a problem. We share the
    concern with the NTSB as well. That is why we, as I said, set
    in place this as a voluntary measure. We have had excellent
    voluntary accommodation of the requirement for a risk
    assessment program. That is also included in our rulemaking.
    Now, I know as far as an actual requirement, many people look
    at that as being a rule, but the rulemaking process does take
    time for reasons that have been articulated here, that we have
    to take into consideration many stakeholders' perspectives on
    the issue and we have to do a thorough analysis on the impact
    on the industry and on the public. So that is why that takes
    time.
        So we have many tools that we can apply to the safety
    equation, rulemaking being one, but voluntary measures being
    the other. So I would submit that when the NTSB brought this
    forward, at the time, yes, they were not employing these
    things, but now, if we go back and reassess that, I would argue
    that they are employing these risk assessment programs and that
    safety is being served.
        Ms. Richardson. Would you agree with that?
        Mr. Sumwalt. That is a reasonable approach. What is your
    voluntary compliance right now?
        Mr. Allen. Ninety-four percent, according to our survey.
        Mr. Sumwalt. Ninety-four percent now, versus a few years
    ago where zero percent was complying. So we feel that we do
    want the regulation to make sure that it is 94 percent, it is
    100 percent, but 94 percent is better than zero percent.
        Ms. Richardson. Okay. Well, let it be said for the record
    that, to me, an issue as serious as this shouldn't be based
    upon voluntary. Whether it is 94 percent or 98 percent, it
    should be 100 percent.
        I want to applaud Mr. Altmire, who I think had a huge role
    in this hearing taking place, and Mr. Costello for supporting
    it. I have been studying his bill, H.R. 978 and am seriously
    inclined to support it. One of the documents, though, that I
    saw said that the AMOA claims that the Patient Safety Act will
    lead to a decrease in aviation safety and allow States to
    regulate aspects of aviation currently under Federal authority.
    Clearly, this legislation would do that, but would you see it
    as really leading to a decrease in aviation safety? Any of you,
    if you would like to comment.
        Mr. Allen. No, ma'am. That is why we are working very
    closely with the staff and we are being very vigilant, that we
    will not let that happen. And I know that we do not want that
    to happen, so we are being very, very judicious and making sure
    the legislation is directed to what it wants to be focused on
    and that we maintain our responsibility and accountability for
    having the overview of the safety issues in terms of aviation
    safety.
        Ms. Richardson. Thank you very much.
        Mr. Costello. The Chair thanks the gentlelady.
        Now, let me thank all of our witnesses. I do have a few
    questions that I will be submitting for the record. We want to
    get to the next panel. But let me thank you for being here
    today and offering your thoughtful testimony. We obviously need
    to continue to work to solution to this critical problem we
    face. So thank you very much for being here and thank you for
    your testimony.
        The Chair will ask the witnesses on our second panel to
    please come forward as quickly as you can. I will introduce you
    as you are being seated.
        On panel 2, Ms. Stacey Friedman, who is the Founder of
    Safemedflight: Family Advocates for Air Medical Safety; Eileen
    Frazer, RN, CMTE, Executive Director, Commission on
    Accreditation of Medical Transport Systems; Ms. Sandra Kinkade,
    who is the President of the Association of Air Medical
    Services; Mr. Matthew Zuccaro, who is the President of
    Helicopter Association International; Mr. Craig Yale, who is
    the Executive Vice President, Air Methods Corporation, on
    behalf of the Air Medical Operators Association; Mr. Jeff
    Stackpole, Council Member, Professional Helicopter Pilots
    Association; Thomas P. Judge, EMTP, Executive Director,
    LifeFlight of Maine, Chair, The Patient First Air-Ambulance
    Alliance; and Dr. Robert Bass, the Chair of the Air Medical
    Committee, The National Association of State EMS Officials.
        So, ladies and gentlemen, if you will take your seats as
    soon as you can, we will hear your testimony.
        We have all of our witnesses at the witness table, and the
    Chair would now recognize Ms. Friedman.
        Again, I would remind all of our witnesses that your entire
    statement will appear in the record in its entirety, and I ask
    our witnesses to try and summarize their testimony under the
    five minute rule.
        Ms. Friedman.

     TESTIMONY OF STACEY FRIEDMAN, FOUNDER, SAFEMEDFLIGHT: FAMILY
       ADVOCATES FOR AIR MEDICAL SAFETY; JEFF STACKPOLE, COUNCIL
      MEMBER, PROFESSIONAL HELICOPTER PILOTS ASSOCIATION; EILEEN
          FRAZER, RN, CMTE, EXECUTIVE DIRECTOR, COMMISSION ON
      ACCREDITATION OF MEDICAL TRANSPORT SYSTEMS; SANDRA KINKADE,
      PRESIDENT, ASSOCIATION OF AIR MEDICAL SERVICES; MATTHEW S.
    ZUCCARO, PRESIDENT, HELICOPTER ASSOCIATION INTERNATIONAL; CRAIG
      YALE, EXECUTIVE VICE PRESIDENT, AIR METHODS CORPORATION, ON
      BEHALF OF THE AIR MEDICAL OPERATORS ASSOCIATION; THOMAS P.
     JUDGE, EMTP, EXECUTIVE DIRECTOR, LIFEFLIGHT OF MAINE, CHAIR,
    THE PATIENT FIRST AIR-AMBULANCE ALLIANCE; AND DR. ROBERT BASS,
    CHAIR, AIR MEDICAL COMMITTEE, THE NATIONAL ASSOCIATION OF STATE
                             EMS OFFICIALS

        Ms. Friedman. I want to thank Chairman Costello, Ranking
    Member Petri, and Members of the Subcommittee for inviting me
    to speak today on behalf of the families of Safemedflight. We
    are a group of families who have lost loved ones in air medical
    accidents.
        We also want to applaud Congressman Salazar for working
    with us, working with industry, and working with the FAA in
    making this bill possible.
        As I said, my name is Stacey Friedman. I am not a pilot. I
    am not a flight medic. I am not a flight nurse. I don't work
    for an air medical program. I am not with the FAA or the NTSB.
    But I am here for one very important reason, and that is
    because of Erin Reed. She was my sister and she died in a
    preventable helicopter crash.
        It has been three years since Erin died, and 45 more
    victims have followed her in death, 35 in 11 months. Voluntary
    compliance did not work for them. The absence of FAA rules did
    not work for those people. These pilots, nurses, medics, and
    their patients died, despite the NTSB's recommendations in
    2006. They died despite the extensive GAO report on this
    industry; they died despite Safety Board hearings; and they
    died despite safety summits in which industry leaders met to
    determine the least possible regulation their pocketbooks could
    afford. Yes, I am a little angry. My husband told me to watch
    it, but I am going to just do it the way I would do it.
        The FAA and the industry originally claimed that safety
    changes were unnecessary and too costly, and they said that we
    were asking the impossible. If we were asking the impossible, I
    wouldn't be here, Sandy Hellman would be here. She would ask
    that you bring back Todd to help her raise their eight adopted
    children with no life insurance and no lawsuit payout. Mason,
    Weston, and Jackson Taylor would ask you to bring back their
    dad to take them to a ball game. ER physician Stacey Bean would
    ask that you restore her faith in air medicine, faith that she
    has lost since the death of her husband, Darren Bean. She no
    longer practices ER medicine. Susan McGlew would ask that you
    bring her brother, Bill Podmayer, home so he could say goodbye
    to his parents, both who died just weeks ago, and Susan buried
    them. Adam Wells would expect you to bring back his wife,
    Jenny, so they could start a family.
        Bringing our people home, that would be asking the
    impossible. Instead, we are asking the FAA and the industry to
    do what is included in Congressman Salazar's bill. We ask that
    operators fly the higher weather minimums and comply with pilot
    duty rest time in Part 135. Why the FAA ever allowed flight
    crews to fly in less safe weather conditions just because there
    wasn't a patient on board is incomprehensible to us. The FAA's
    recent change on weather minimums is years too late and no
    guarantee that operators will not push weather in this
    hypercompetitive market.
        We ask that operators use a risk assessment prior to
    accepting a flight. EMS flight risks are well known and
    documented, and we have talked about them today. They include
    weather, obstacles and terrain, nighttime flight, spacial
    disorientation and pressure to take a flight. A longstanding
    FAA notice required operators to complete a risk assessment.
    Yet, recently, at least two fatal accidents, killing eight
    people, involved operators who failed to comply with this
    notice: Alaska in December of 2007; Illinois in October of
    2008. Why are operators who violate FAA notices and kill flight
    crew and patients allowed to operate? That is a question we
    have.
        We ask that flight dispatch and flight following procedures
    be required and that dispatchers have aviation specific
    knowledge. In June, a midair collision in Arizona killed seven.
    Both aircraft were scheduled to arrive at the same helipad
    within minutes of each other, yet, neither pilot received this
    information.
        We ask that EMS operators carry cockpit recording
    technology to determine the cause of accidents, prevent future
    accidents, and answer the questions of family members. We ask
    that operators install existing and proven technology that
    helps pilots avoid terrain and collision with obstacles, and we
    include night vision goggles in this category.
        We are not asking the impossible. We are asking operators
    to keep our people safe. And if their response is we can't
    afford it, then they shouldn't be in a business that rests its
    reputation on saving lives.
        To close, I would like to tell you something about what I
    believe happened on September 29th, 2005. That night changed
    everything for my family and left me without my sister. I
    believe the pilot, Steve Smith, did everything he could to keep
    Erin and Lois alive. And I believe the circumstances of that
    evening got the best of them. I believe that if they had had
    the technology and the systems in Congressman Salazar's bill,
    as well as night vision goggles, they would be alive today, and
    I believe dozens of others would be alive today as well.
        I want to thank you for giving us a voice at this hearing.
        Mr. Costello. Ms. Friedman, thank you. Thank you for being
    here on behalf of Erin and the other victims.
        The Chair now recognizes Mr. Stackpole.
        Mr. Stackpole. Good morning. My name is Jeff Stackpole. I
    am currently working as a full-time line pilot flying an
    emergency medical services helicopter in the St. Louis,
    Missouri area for our Chair Medical Services, a wholly-owned
    subsidiary of Air Methods Corporation. I am also the President
    of Air Methods Pilots Union, Local 109, of the Office of
    Professional Employees International Union. By virtue of that
    office, I serve as a council member of the Professional
    Helicopter Pilots Association, the organization you have
    invited to participate in today's hearing.
        PHPA represents approximately 400,000 helicopter pilots, of
    which 1500 or so are working HEMS pilots. On behalf of those
    dedicated professional men and women, I would like to thank the
    Committee for focusing its attention on the difficulties
    currently being experienced by our industry. While this is
    certainly an important subject for all involved in this
    process, no one has as much at stake on the outcome as do the
    pilots we represent. Likewise, we believe, no one has as much
    to contribute to the process of figuring out how to improve the
    safety of this industry than those who perform the job on a
    daily basis.
        While this is a complex issue with no simple solution,
    solutions do exist, and action must be taken to ensure those
    are implemented. PHPA has submitted to this Committee a
    detailed list of areas of concern, as well as recommended
    actions that we believe are necessary to achieve our common
    goal, which is, of course, the reduction of preventable
    accidents in HEMS operations.
        While we would like to believe that the free market system
    would resolve these issues for us by eliminating marginal
    operators and rewarding those operators that spend the
    additional funds necessary to properly equip, train, and
    support the safest possible operations in what we all agree is
    a much needed public service, this has proven not to be the
    case. Unfortunately, those requiring air medical transport
    typically have no input as to the operator that will be
    utilized to provide that service, thereby economically
    disadvantaging those operators who, in the interest of
    enhancing safety, choose to provide more than the very minimum
    required by statute to accomplish the task.
        Another aspect of our industry that has the same effect as
    that just described is that of reimbursements. It is our
    understanding that neither Medicare, Medicaid, nor private
    insurance offer any additional compensation based on the type
    of helicopter utilized, the training and experience levels of
    the crew, or any other safety enhancing initiative that one
    operator may offer over another. Add to this the fact that
    Medicare and Medicaid reimbursements often do not even cover
    the costs of providing the basic service, it is not difficult
    to understand the economic disincentive that exists for any
    operator striving to achieve the safest operation possible.
        In addition to these economic issues, our industry is
    burdened with another issue not foreign to other aviation
    operations, however, for us it is multiplied exponentially, and
    that is the pressure to fly. For some, this pressure is
    completely self-imposed by the knowledge that almost every time
    a flight is requested there is a patient possibly in dire need
    of our services. For others, unfortunately, there are external
    pressures in the form of a customer questioning a pilot's
    decision to decline a flight request.
        While the FAA has made a concerted effort to address the
    issue of operational control, it is the opinion of PHPA that
    this effort needs to go further. For example, we believe that
    it is inappropriate for a hospital customer to participate in
    the process of selecting the pilots that their vendor chooses
    to provide, and that it is equally inappropriate for a hospital
    customer to have the ability to have a vendor remove a pilot
    from their program without justification. It seems overly
    apparent to us that this type of arrangement can and does erase
    the lines of operational control that are vital for the
    certificate holder to maintain.
        PHPA and the pilots we represent appreciate the efforts of
    those Members of Congress who have introduced legislation
    addressing safety issues in HEMS operations. And while we do
    not disagree with the contents of the current bills, we feel
    that stronger, more comprehensive language is necessary to
    bring about the improvements we are all hoping for. In spite of
    the fact that most helicopter pilots are conservative in nature
    and would normally agree that less government involvement in
    our business is better than more, we find ourselves conceding,
    at least in this situation, that government intervention may be
    the only way to achieve any real progress.
        We ask that you review the information we have submitted
    and consider addressing as many of the concerns we have raised
    as you feel may be appropriate in any current or proposed
    legislation. Thank you for inviting the Professional Helicopter
    Pilots Association to address this Committee, and please call
    on us for any assistance we may be able to provide in advancing
    this important effort.
        Mr. Costello. The Chair thanks you and now recognizes Ms.
    Frazer.
        Ms. Frazer. Thank you, Mr. Chairman. The Commission on
    Accreditation of Medical Transport Systems was formed in 1990,
    after a rash of accidents that occurred in the mid-1980s. It is
    a voluntary, not-for-profit agency. We have 17 member
    organizations. Each member organization sends a representative
    to serve on the board of directors, and all of those represent
    all of the constituents within medical transport.
        The most important part of what we do is accreditation
    standards. These standards are used worldwide because it is the
    only body of standards that look over the wide range of
    programs within an air medical and ground transport service.
    They cover things like patient care, crew training, staffing,
    scheduling, management, aircraft medical configuration,
    communications, helipads, quality management, safety management
    systems, infection control, and so on.
        Every two years, we revise the standards to reflect the
    current dynamic changes, and in developing and revising
    standards, we do talk with the NTSB, our Federal partners at
    the FAA, we get input from all of our constituents and groups,
    and we can move quite quickly with standards. For example,
    after the rash of accidents last summer, the board met and we
    looked at some of the preliminary reports that came out by the
    NTSB. In looking at those, we quickly developed some standards,
    especially looking at fatigue, which was really a concerning
    issue not only for night flights with the visual and the
    weather conditions, also fatigue, we felt, was a really strong
    concern. We also addressed the hospital helipad communications
    and better crew coordination with the helipads.
        So those standards came out within six months and were
    approved.
        As far as the Federal partners, we are required by the
    Department of Defense and we are required for civilian, medical
    air transport contracts, as well as by Indian Health Services.
        I want to talk about the States a little bit because that
    is addressed and was discussed earlier. There are currently
    five States that do not have any air ambulance licensing
    procedures at all. In nine States they require CAMTS
    accreditation, and those States are Colorado, New Mexico, Utah,
    Washington, Michigan through their CFN process, New Hampshire,
    Rhode Island, Massachusetts, and Maryland. So, currently, there
    are nine States that require CAMTS accreditation. Some counties
    in California and Clark County in Nevada.
        This absolutely puts us, though, in a litigation process,
    because if we withdraw accreditation in those States, that
    means that company is not allowed to operate in that State and,
    therefore, we have a legal issue. So we are working with those
    States on those issues right now. We do support the States.
    They do have the responsibility for the health care of the
    individuals on board.
        As far as the Salazar bill, all patient mission flights
    under our standards must be conducted under Part 135
    regulations. We have had that since 2006. We also require
    operation risk analysis tools and specifically check that each
    time we go out and visit a program.
        That concludes my testimony. Thank you.
        Mr. Costello. The Chair thanks you, Ms. Frazer, and now
    recognizes Ms. Kinkade.
        Ms. Kinkade. Mr. Chairman, Ranking Member Petri, and
    Members of the Subcommittee, thank you for the opportunity to
    share our perspective on the topic of oversight of helicopter
    medical services. I am Sandra Kinkade, President of the
    Association of Air Medical Services, or AAMS. During the course
    of my career, I have worked as a flight nurse in Nevada and
    Tennessee for 13 years, and now have my own international
    consulting firm.
        Established in 1980, AAMS is a longstanding trade
    association representing 300 air medical transport services
    using both helicopters and fixed wing airplanes operating out
    of nearly 700 bases across the United States. Each year,
    approximately 4,000 of our Nation's sickest and most critically
    injured patients are transported.
        Most people don't realize the life and death role that
    emergency medical helicopters play in our health care system,
    but the critically ill and injured are airlifted once every 90
    seconds in our Nation. That is why it is important not to
    underestimate the value of air medical services, because the
    life saved might be yours or a loved one's.
        I would like to remind the American public of the following
    important facts related to air medical services in the United
    States today. Helicopter EMS provides safety, speed, access,
    and quality of patient care, and serves as the rural health
    care safety net, particularly in underserved areas. Medevac
    helicopters provide a quicker response and a higher level of
    medical care than is typically found on a ground ambulance. A
    typical medevac crew consists of a specially trained critical
    care nurse and paramedic, and can also include other
    specialists, as needed, depending on the patient's condition.
    In rural or wilderness areas, or in cases of natural or
    catastrophic disasters, air ambulances may be the only
    accessible health care provider available.
        Medevac helicopter crews do not self-dispatch; a flight
    request is generally made by a physician, nurse, law
    enforcement officer, fire service or emergency medical
    responder, as dictated by local, regional, or State protocols.
    Demand for medevac helicopters is on the upswing, partially as
    a result of aging baby-boomers whose related health care
    problems, most notably stroke and heart attack, are placing a
    greater demand on the overall health care system, as well as
    creating a need for highly time dependent emergency medical
    interventions. Greater reliance on medevac helicopters is
    particularly prevalent in rural and retirement areas, and in
    places that have experienced emergency room closures or
    cutbacks in local community-based ambulance services or
    hospitals.
        Clearly, the goal of air medicine is to improve health
    outcomes for our patients. Our goal has been, and continues to
    be, zero accidents. To that end, the industry has undertaken
    numerous voluntary efforts to advance safety on each and every
    mission. Additionally, we have put forward several proposals
    aimed at making medical helicopter flights safer. Chief among
    these proposals is that all medical night flight operations be
    required to either utilize night vision goggles or similar
    enhanced vision systems, or be conducted strictly under
    instrument flight rules.
        AAMS recommends that Congress expedite funding for hospital
    helipads, enhanced off-airport weather reporting, global
    positioning system technologies, and other initiatives. AAMS
    recommends that the FAA accelerate implementation of automatic
    dependent surveillance broadcast systems, also known as ADSB,
    for the HEMS operating environment. In addition, implementation
    of associated weather reporting and enhancements to the
    Nation's low altitude aviation infrastructure should become an
    FAA priority. Further, AAMS recommends that the FAA, in
    coordination with the industry, establish requirements and
    procedures for utilizing devices that play a role in flight
    operations quality assurance programs, also known as FOQA.
        AAMS commends Congressman Salazar's current initiative to
    advance helicopter EMS safety in introducing H.R. 1201.
    Overall, AAMS is supportive of anything that will help make our
    community and the missions we conduct safer. We have made some
    recommendations in our written testimony that we believe will
    strengthen the language and are very happy to hear from the
    Congressman today that some of those recommendations have been
    included in the recent bill changes.
        AAMS and its members believe that the only appropriate
    safety goal for this community is one of zero accidents. We
    stand ready to work collaboratively with legislators,
    regulators, and the public to combine our best thinking and
    target our efforts to maximize the effectiveness of safety
    initiatives and to dramatically lower the risks associated with
    air medical transportation.
        I just want to thank Stacey for being here and your
    leadership and giving a voice to those who no longer can.
        Mr. Costello. The Chair thanks you for your testimony and
    now recognizes Mr. Zuccaro.
        Mr. Zuccaro. Good morning, Chairman Costello and Ranking
    Member Petri. Thank you for the opportunity to speak with you
    today.
        I would like to acknowledge one fact that I truly believe
    that everybody that is in the room today shares a common goal
    towards the enhancement of safety. I believe we acknowledge
    also that we have differing opinions as to how to reach that
    goal. My comments are made in respect to those opinions.
        HAI represents the international helicopter community. It
    is a not-for-profit professional trade association with over
    2,900 members, inclusive of 1,400 companies and organizations.
    HAI members safely and professionally operate in excess of
    5,000 helicopters, fly more than 2 million hours per year.
        We represent 93 medical service providers providing service
    throughout the United States. These operators are comprised of
    74 commercial operators, 17 government service operators,
    flying a total of 1,219 aircraft, which we estimate represents
    90 percent of the helicopter EMS operations being conducted in
    the United States.
        HAI, in fact, believes the current emergency medical
    services accident rate is unacceptable and that these recent
    series of accidents were preventable. We fully support any
    initiative that improves the safety of EMS operations and
    recommend a cooperative effort between industry and FAA, with a
    resulting FAA rulemaking initiative, as necessary, to achieve a
    safer EMS industry. In recognition of this, HAI has worked with
    EMS operators to mitigate accidents, emphasizing safety
    management systems, extensive use of them, emphasizing risk
    management. HAI has been instrumental in working also closely
    with the FAA in developing long-term initiatives addressing
    such issues as 135 versus 91 operations on all the legs,
    utilization of such technology as night vision goggles, radar
    altimeters, HTAWS, devices that perform the function of CVR/
    FDR, operational control centers, and formalized risk
    assessment/hazard mitigation programs.
        HAI has also been an industry leader by sponsoring numerous
    safety forums that were focused on helicopter EMS operations.
    Participation in these forums also involved industry, as well
    as executive level representation from the FAA and the NTSB,
    all working towards our common goal of enhanced HEMS safety.
    HAI has also committed resources and staff in the efforts of
    the International Helicopter Safety Team, a worldwide
    international industry initiative with a goal of reducing
    helicopter accidents by 80 percent within the next 10 years. I
    am honored to serve as the co-chair of this international
    effort, which is a data driven analysis process and was modeled
    after the successful CAST program utilized by scheduled air
    carriers.
        As a result of a recent in-depth collaborative industry/FAA
    effort, coordinated by HAI, FAA revised Part 135 HEMS Ops Spec,
    A021, setting forth detailed flight planning and increased
    weather minimums for HEMS operations.
        Of equal importance, we strongly believe there is a need to
    secure Federal funding for remote weather stations that would
    fill existing gaps, especially at night, and the availability
    of off-airport automated weather reporting stations to support
    helicopter HEMS. There is also a critical need for a dedicated,
    low altitude IFR helicopter route structure with the associated
    instrument helicopter approaches to hospital heliports and
    other locations such as accident scenes. This will provide all
    weather helicopter instrument flight capability for emergency
    services in the public interest, which is consistent with the
    public expectation and the necessity for such services. Any
    funding initiative should be inclusive of research and
    development of advanced technologies to facilitate this
    capability.
        Earlier last year, the National Transportation Safety Board
    completed a four day safety hearing on the subject of HEMS. HAI
    was a designated party to and witness at the hearings, and
    continues to serve as a major contributor to the NTSB/FAA
    efforts. Of note, 80 to 85 percent of the accidents, when
    studied, related to human factors decision-making, not to
    technology and not to regulatory deficiencies. That is an area
    that we all need to concentrate on, the actual way the business
    is conducted and the human factor decision-making that occurs
    within it.
        H.R. 1201, the Salazar legislation, aims to increase safety
    for crew and passengers on aircraft providing emergency medical
    services, and would require EMS pilots to comply with 135
    regulations whenever there is a medical crew on board,
    regardless of whether a patient is also on board. There is some
    distortion in the statistics. I would quickly point out that
    when the NTSB categories an accident and notes that there is no
    patient on board, they automatically put in Part 91 operation.
    That may not be the case. It does not recognize the fact that
    the operator was actually operating under Part 135, and that is
    not noted.
        HAI believes the actual question that should be addressed
    regarding medical personnel and the conditions when they are on
    board the aircraft relates to their status, as to whether they
    are passengers or crew members. Once a resolution is reached on
    this issue, then the proper regulatory guidance can be applied,
    be it FAR Part 135 or 91. HAI believes that Congress should
    task the FAA with resolving this matter.
        We are a strong advocate of flight risk evaluation,
    including usage of standardized checklists, risk evaluation to
    determine whether a flight should be conducted. A collaborative
    effort between the FAA and the air medical community should be
    undertaken to develop performance-based flight dispatch
    procedures and methods to measure the compliance. As
    appropriate, feasibility studies should be conducted by the FAA
    administrator on devices that perform the function of recording
    voice communication and flight data information on new and
    existing aircraft.
        With regard to FAA rulemaking itself, it should be the
    venue to effect safety initiatives and not legislative action.
    We do acknowledge the current FAA rulemaking process is really
    not acceptable in terms of the length of time it takes to
    effect a rule change. Clearly, the FAA rulemaking process is
    not timely and needs to be revised. Accordingly, Congress
    should direct the FAA to review its current rulemaking
    procedures and revise the same to expedite the implementation
    of beneficial safety initiatives when appropriate.
        I would point out that there is a system and it is not
    functioning the way it should, and we should not circumnavigate
    it with legislative initiative. Fix the system and make it
    operate properly so that we can maintain the notice of proposed
    rulemaking process.
        Mr. Altmire's legislation, 978, is asking for a change as
    it relates to health planning and patient safety to allow
    States to regulate aviation operations, which are already
    covered. The Department of Transportation has concluded that a
    State is free to regulate the medical issues associated with
    EMS service, including establishment of minimum requirements
    for medical equipment, training, and personnel. We highly agree
    with that. The bill does not really seem to address the safety
    deficiency, but rather an economic regulation and resultant
    entry control limits as to who can conduct the EMS, thereby
    eliminating robust competition so required by the public
    interest.
        Helicopter operators do not decide who to transfer or
    transport; the medical community does that. Where is the direct
    correlation or research that indicates the number of HEMS
    accidents in a given area is directly related to the number of
    providers in that area? What about the potential impact of H.R.
    978 on other segments of the industry and other types of
    helicopter operations that find a necessity to cross State
    lines that would ultimately be affected by this? Congress
    should not allow the States to regulate the issues.
        The unanswered question should be H.R. 978, how will it
    make EMS aviation safety for the better?
        With that, I would close my comments, Chairman, and be glad
    to take any questions.
        Mr. Costello. The Chair thanks you and now recognizes Mr.
    Yale.
        Mr. Yale. Thank you, Mr. Chairman, Members of the
    Subcommittee. My name is Craig Yale, and I am Vice President of
    Corporate Development for Air Methods Corporation. I am here
    today on behalf of the Air Medical Operators Association, or
    AMOA.
        AMOA represents air carrier certificate holders providing
    medical transportation operations, whether their fleet size is
    a few or several hundred aircraft. On behalf of our members and
    the over 8500 employees represented by the Association
    nationwide, I would like to thank the Members of the
    Subcommittee for the opportunity to offer this testimony and
    your interest in air medical transportation safety and
    effective oversight.
        I too am very passionate about this subject. I have over 30
    years experience providing medical transport. My experience in
    that time encompasses both profit and not-for-profit
    organizations providing helicopter, fixed wing, and ground
    ambulance services.
        Air Methods Corporation, with approximately 350 aircraft
    operating in 42 States across the Country, is not only the
    world's largest commercial air medical company, but by fleet
    size is the tenth largest air carrier in the United States, to
    include the major airlines. Air Methods operates through both
    community-based air medical transport services, at the request
    of others without knowledge of the ability for our patient to
    pay, and as a contract aviation service provider to hospitals
    engaged in air medical transport services.
        The Air Medical Operators Association was formed to
    coordinate and enhance the collaborative efforts of Part 135
    medical air carriers on matters of safety, access, and quality
    operations. AMOA's members represent the air carrier operations
    of over 700 medical aircraft and approximately 92 percent of
    the civil helicopter medical airlift capacity in this Country.
    Many of these aircraft are utilized by hospital programs as an
    indirect air carrier, and I will not presume to speak for these
    entities, as there are others on the panel here for that
    purpose. However, it is important to understand that Part 135
    air carrier responsibility for the overwhelming majority of
    these programs rests with AMOA's members.
        AMOA strongly supports the intent of H.R. 1201. The
    provisions of H.R. 1201 are rooted in safety recommendations
    made by the NTSB's special investigation report on emergency
    medical service operations adopted in January of 2006. The
    recent public hearings held by the NTSB reviewed both the FAA's
    and the air medical industry's response to those
    recommendations. As evidenced by the hearings, we believe that
    the air medical operators have met, and in some cases exceeded,
    the intent of those recommendations. We are in favor of
    codifying these advances through regulation, but would suggest
    the use of rulemaking process to avoid unintended consequences
    of the rigid interpretation potential there is in legislative
    language.
        As an example, all operations must comply with the
    regulations of Part 135 of Title XIV, Code of Federal
    Regulations, whenever there is a medical crew on board would
    actually require less stringent weather minimums than those
    currently in place through A021 Operations Specifications. We
    agree with the need for regulation, but respectfully would
    request the opportunity to fine-tune the process in conjunction
    with the FAA through the rulemaking process.
        We are, however, greatly concerned with the language and
    underlying intentions associated with H.R. 978. All legal
    interpretations and judicial rulings have clearly stated that
    aviation operations fall within the Federal purview, while
    States maintain control and responsibility for medical
    operations. Since the State's right to oversee medical
    operation of helicopter services is uncontested, it would
    appear that the intent of this legislation ultimately distills
    to an attempt to control and restrict the entry of air medical
    operations within a State's boundaries.
        Quoting a representative of the U.S. Department of Justice
    Antitrust Division, certificate of need laws pose a substantial
    threat to the proper performance of health care markets.
    Indeed, by their very nature, CON laws create barriers to entry
    and expansion, and are thus anathema to the free market. They
    undercut consumer choice, weaken markets' ability to contain
    health care costs, and stifle innovation. He went on to say
    that CON laws appear to raise particularly substantial barriers
    to entry and expansion of competitors because they create an
    opportunity for existing competitors to exploit procedural
    opportunities to thwart or delay new competition.
        It is interesting to note that of the six States currently
    exercising CON processes as it relates to air medical services,
    each State has fewer air medical services per capita than the
    national average. Emergency preparedness is about capacity and
    access. It is AMOA's belief that H.R. 978 would severely limit
    this Country's timely access to air medical services and would
    reduce the ability to flex a response as necessary for natural
    and other disasters. States should in fact meet their
    responsibilities to oversee medical components of emergency
    services. However, the responsibility for oversight of the
    Nation's air carrier operations needs to remain in the expert
    hands of the FAA and DOT.
        Thank you, sir, for your time.
        Mr. Costello. The Chair thanks you, Mr. Yale, and now
    recognizes Mr. Judge.
        Mr. Judge. Good afternoon, Chairman Costello, Ranking
    Member Petri, and honorable Members of the Committee. I am
    Thomas Judge and am testifying on behalf of The Patient First
    Air-Ambulance Alliance, PFAA, which represents 70 air medical
    providers in 40 States, including several members of AMOA. In
    addition to professional roles in air medicine, I have worked
    in rural EMS systems for over 30 years. Assuring access to care
    is a personal imperative.
        The Alliance was simply created to improve the
    accountability of the air medical system to patients and the
    public. It is extremely regrettable that HEMS has ended up on
    the NTSB's most wanted list. While significant progress is
    being made in improving air medical safety, more must be done.
    A strictly voluntary approach in which individual providers
    define their own standards is not working, as documented by the
    Flight Safety Foundation.
        While we strongly support single system aviation safety
    oversight by the FAA and recognize the contributions of the ADA
    to commercial travel, we are here today because HEMS is a
    unique sector of aviation. HEMS is an essential emergency
    service within a system, more akin to a public utility than an
    enterprise. In an emergency, the public must trust that every
    decision on their behalf is made strictly on the basis of best
    medical and aviation practice.
        The public perception of the system and the reality however
    are at odds. The public believes that all medical helicopters
    have the same level of performance and aviation safety
    technology. They do not. The public believes that if they need
    air medical transport, the helicopter that arrives will take
    them to the right hospital, the right physician at the right
    time. That may or may not be true, depending on where they
    live. The public believes that the helicopter will be staffed
    by qualified medical crews with the latest medical technology
    to provide them with critical care. There is no such guarantee.
        Our testimony includes are all too common story of
    uncoordinated care. While critics of H.R. 978 have said it
    would lead to multiple State standards, we are actually seeing
    the situation where individual providers set their own
    standards and can challenge any imposition of public
    accountability by claiming economic regulation preempted by the
    ADA.
        When I was the president of AAMS, I believed the industry
    could self-regulate. I was wrong. The rapid growth of
    providers, underlying economic challenges in air medicine, and
    the use of the ADA to strike down State regulations have come
    together as a perfect storm, compromising both patient and
    aviation safety. We see providers based in locations by payer
    profile rather than need, often resulting in geographic
    maldistribution of services; providers maximizing flight volume
    over patient and aviation safety due to the need to meet high
    fixed costs; providers working outside the EMS system;
    providers transitioning to less capable aircraft. For example,
    in Kansas City, a twin engine fleet became a single engine
    fleet, antithetical to the FAA's current efforts to incentivize
    IFR.
        As slide 1 shows, saturated competitive markets actually
    work in contrast to the goals of ADA, actually increasing cost
    to the health care system and to patients.
        The intersection of Federal and State law over HMS is truly
    unique. While the FAA must oversee aviation safety, HEMS is the
    only area of aviation where the States have a role and
    legitimate interest because the passenger is a patient
    receiving critical care. Unlike other commuter operations, our
    passengers are critically ill, so they can't be considered
    informed consumers. HEMS is the only area of health law in
    which States are limited or prevented from regulating as they
    do all other health care services within their borders. Medical
    helicopters are both ambulances and aircraft. State regulation
    over ``medical'' is more than simply the medical care provided
    in the helicopter. State regulation must encompass the entirety
    of medical helicopter services, meaning system integration,
    coordination, and quality.
        States are currently prohibited by the ADA from fully
    regulating medical services in the way they regulate all other
    health care services. The ability of States to regulate the
    ``ambulance'' aspect of HEMS has been challenged in numerous
    areas, leaving enormous gaps in oversight, lack of clarity over
    what States can and can't regulate, and a chilling effect on
    State regulators to strengthen or even enforce existing HEMS
    regulations.
        States can't require 24-hour availability, determine base
    location, require scene transports regardless of insurance, or
    require integration with the EMS system. How is the public
    served by an emergency service system that does not guarantee
    24 hour access? States can regulate the medical care and
    equipment, but as Representative Altmire noted, in Hawaii,
    quality, accessibility, availability, and acceptability are
    impermissible under the ADA. Something as simple as requiring
    climate control to prevent cold babies or a heart attack
    patient has never been explicitly permitted and is currently
    being challenged in North Carolina right now.
        Contrary to assertions that 978 does not limit access to
    needed services, it only applies to intrastate point-to-point
    transport. Indeed, cross border operations occur daily and will
    continue to occur if 978 is enacted.
        Slide 2 further illustrates how this works, the interstate
    operations. Massachusetts and Connecticut, with the fewest
    number of helicopters, have the best trauma preventable death
    outcomes in the Country. The number of helicopters is not
    really at issue.
        An unregulated market does not guarantee access to
    emergency care. The assertions that this will limit access in
    rural areas is just really untrue. All of the growth, as seen
    in the ADAMS database, is actually in areas in the last five
    years that are already served by helicopters. By establishing a
    clear boundary, 978 will lead to a safer and higher quality
    HEMS system, provide more accountability, and lead to a more
    harmonized and predictable State regulation benefitting Federal
    and State regulators and providers.
        We also endorse 1201 as an essential means to improve
    aviation safety. As with H.R. 978, there is an opportunity to
    improve and strengthen the bill, especially around building and
    supporting a low level IFR system.
        In conclusion, HEMS is not an aviation enterprise, but an
    emergency public utility. We strongly believe a rebalancing and
    clarification of the lines of conflicting regulatory authority
    are necessary if we are to effectively address and improve both
    aviation and patient safety, and we appreciate your time.
        Mr. Costello. The Chair thanks you, Mr. Judge, and now
    recognizes Dr. Bass.
        Dr. Bass. Good afternoon, Chairman Costello and Ranking
    Member Petri. I am Dr. Robert Bass and I am testifying on
    behalf of The National Association of State EMS officials that
    represent EMS officials in the 56 States and territories. I am
    an emergency physician. My day job is a State EMS director in
    Maryland.
        EMS and trauma systems, we know they save lives, and a
    breakdown of those systems can cost lives. In previous decades,
    helicopter EMS, or HEMS, as we call it, were well integrated
    into our trauma and EMS systems. Today, in many States, that
    integration is lacking and the system is broken.
        In early 2000, shortly after Medicare improved its
    reimbursement practices for HEMS, the industry began to
    experience extraordinary growth throughout the Country.
    Unfortunately, more helicopters doesn't always mean more access
    or better care. In many cases, it simply means more helicopters
    on top of one another in urban areas. Some HEMS operators have
    been utilizing the preemption provision of the Airline
    Deregulation Act in an attempt to dismantle the EMS and health
    planning provisions in many States.
        In addition to the ADA challenges, letters of opinions from
    the U.S. Department of Transportation have provided conflicting
    guidance on preemption issues. In one recent DOT opinion, they
    recognized the authority of States to regulate basic staffing
    requirements, qualifications of personnel, equipment
    requirements, and sanitary conditions. However, in another DOT
    opinion, requirements related to quality, availability,
    accessibility, and acceptability were viewed as being
    preempted. Other language has left States unclear as to the
    extent to which they can require medically necessary, but
    expensive, life-saving equipment.
        The effect of the ADA related judicial decisions and the
    DOT letters has had a chilling impact on State efforts to
    regulate the medical aspects of HEMS. In many States, EMS
    officials are increasingly concerned about time-consuming,
    costly, and potentially damaging lawsuits. States must have
    clear and sufficient authority to fulfill the public trust in
    planning, coordinating, integrating, and regulating air
    ambulances as a component of the overall EMS system, just as
    they do for ground ambulances. This was a key recommendation of
    the 2006 IOM report that was previously referred to.
        The difference between aircraft operations transporting
    passengers and those transporting patients are important, and I
    would like to take just a moment to emphasize those
    differences. First, while a medical helicopter is an air
    carrier, first and foremost, it is an ambulance which provides
    very sophisticated patient care. Second, while airline
    passengers typically choose their mode of transport and
    airline, EMS patients and their families generally cannot.
    Third, HEMS providers must function as part of another system,
    the EMS system, and that is necessary to save lives.
        NASEMSO supports H.R. 978, which would provide States the
    unambiguous authority to determine the need for and
    distribution of HEMS resources, as well as to regulate other
    essential medical aspects of HEMS, including the adequacy of an
    aircraft to serve as an ambulance by addressing issues such as
    access to the patient and climate control for vulnerable
    patients.
        We have heard concerns about H.R. 978, so allow me to just
    take a moment to address a few of them.
        First, opponents argue that the bill would limit access to
    HEMS services in rural and underserved areas. We don't believe
    that to be true. What it would potentially do is to enable
    States to limit the number of helicopters in oversaturated
    markets and improve access to HEMS services in other areas of
    the State. Second, H.R. 978 doesn't tell a State it must
    regulate or that, if it does regulate, it must regulate in a
    certain way. The bill appropriately leaves that up to the
    States. Third, H.R. 978 does not impede the interstate
    transport of patients. Medical helicopters move across State
    borders everyday, just as ground ambulances do. H.R. 978 does
    nothing to change that. Fourth, H.R. 978 does not interfere
    with the FAA authority to regulate aviation safety. Both the
    Federal Government and the States are trying to protect the
    same person who is both a passenger and a patient. Fifth, there
    is a precedent for H.R. 978 in the exemption from preemption
    that is afforded States with respect to motor carriers.
        It is estimated that over 4.5 million patients have been
    flown by medical helicopters over the past 30 years. The
    medical care and rapid transportation provided by HEMS has
    undoubtedly saved many thousands of lives. As reported by the
    Institute of Medicine in 1999, an estimated 131 to 292 deaths
    per 100,000 patients occur due to adverse events during the
    course of routine medical care. The need for aviation safety is
    clear. However, it must not negate the need for patient safety,
    or many lives will be lost.
        Our association believes that more clearly defined Federal
    and State roles and authority would lead to safer and more
    effective utilization of HEMS in the United States, and we
    thank you for your consideration.
        Mr. Costello. Dr. Bass, thank you for your testimony.
        Mr. Stackpole, let me ask a couple of questions, if I can.
    You state in your testimony that better guidelines for new HEMS
    pilots training are needed to ensure that solo pilots are
    properly prepared. Do you want to elaborate on that a little
    bit?
        Mr. Stackpole. Well, sir, I think that as we discussed
    earlier today, as you heard in earlier testimony, HEMS is a
    unique aviation operation, so no matter where a pilot comes
    from or gains his initial experience to come to work at a HEMS
    operator, he needs specific training in relation to the
    operation he is going to be conducting, and, currently, there
    are many operators that fly aircraft that don't allow for
    training a pilot in an actual HEMS flight. In other words, he
    is provided training prior to going on to the line, but once he
    has gone through his initial training, he is basically turned
    loose on his own.
        Mr. Costello. You also say, and I quote, ``real change will
    not occur through voluntary compliance, some initiatives must
    be mandated.'' I would like you to elaborate on that as well.
        Mr. Stackpole. Well, I mean, I have been doing this job for
    nine years, and I started in a program, the program that I am
    still working at. We have a multi-engine aircraft that is not
    certified for IFR but does have full instrumentation. But I am
    seeing at our program the degradation of the equipment that we
    utilize. We are being reduced to single engine aircraft at some
    of our outlying bases; open cockpit or no longer is there
    separation. The aircraft that I fly is not only multi-engine,
    but also is a cabin class aircraft, so I have complete
    separation from the medical treatment that is occurring in the
    back. I think that is a very important issue for the safety of
    the HEMS flight. We are seeing new aircraft that are coming
    online that don't have that, and we think that is something
    that should be regulated.
        Mr. Costello. Thank you.
        The Chair now recognizes the Ranking Member, Mr. Petri.
        Mr. Petri. Thank you very much and, again, thank you, Mr.
    Chairman and all of the panelists for your testimony.
        I really just have one question, and I don't know who I
    should direct it at particularly. This is clearly a heart-
    wrenching situation and there is an even broader aspect to it,
    the loss of life of crew members and passengers is tragic. On
    the other hand, you are in an emergency situation and someone
    may be dying in an auto accident or because of heart failure or
    some other thing that conceivably could be prevented if there
    was quick action taken.
        Is that an aspect of the problem too? Are there cases, do
    we have any statistics where people could have been saved, but
    the crew or the airline company said, well, we are going to
    save the equipment and it really wasn't that dangerous, but we
    are not going to go ahead and do it, and a family has lost
    their father or their wife or some other thing? How do you
    balance these sorts of situations is what I am asking.
        In my own case, in our business, politicians are
    competitive and they are always trying to push and take private
    flights. We have a long list of colleagues who have died in
    airline accidents, both helicopter and plane, all the way from
    Hale Boggs, who is a famous figure around here still, to Paul
    Wellstone, who evidently shouldn't have done that, but he was
    trying to go to some meeting and the pilot went along with it,
    and Don Pane just was shot at, pushing the envelope a little
    bit over Mogadishu, fortunately survived; Nicky Edwards didn't
    over in Africa.
        These are tragic situations. How do we balance all this?
    And I suppose you think about it all the time, but is there
    another side to it in terms of people who are dead because they
    could have been saved and weren't?
        Mr. Zuccaro. I would like to take an initial stab at that.
    Everything that has been spoken about here I think has to be
    focused on the relation to the human factors issue and the
    decision-making, and remove the technology and the regulatory
    environment. I think that is where we find that most of the
    accidents and the causal effects are, is how that decision was
    made to launch on that flight and what the human factors are.
        We are all human beings, and I think as has been noted by
    several of the panelists that this is a special environment;
    there is a life at stake, and I think that is a contributory
    aspect to this as to the decision-making. Nobody wants to be
    the one to say I can't go because of the weather or the
    conditions, and realize that they might have a material effect
    on the outcome of someone's life. We try to respond to that as
    human beings, and that is one of the areas that we are
    concentrating on in the safety initiatives, as well as
    everybody on the panel.
        But in order to try to get it to best capability, there is
    a critical need to separate the medical environment and the
    aeronautical environment and the decision-making. In my thought
    process, you have to view the medical mission as a transport
    mission. The pilot and the company are being asked to transport
    an aircraft from A to B, and to do it safely and
    professionally. I think we need to apply the logic that what is
    going on in the back of the aircraft, be it medical, be it a
    passenger for some other purpose, is not germane to that
    aeronautical decision.
        If you start building in the fact that, on this flight, it
    is a patient's life might be affected versus a corporate person
    might want to go from A to B, you start changing the model for
    the decision-making, when the real question has never changed:
    Can you do this safely or not from A to B? And the pilots need
    to be in an environment that is removed from the medical
    influence so that they truly are only asking and answering an
    aeronautical decision-making question. And I think that would
    go a long way to enhance the decision-making human factors
    issue.
        Mr. Costello. Mr. Judge?
        Mr. Judge. Certainly, I work as a paramedic everyday, so I
    take care of patients in a very rural area. Our State does
    require us to be available 24/7 in the flight medical system.
    They do not, however, require us to fly. They require us to be
    integrated into the care system so that there is an option for
    that pilot to be able to say no and still know that the patient
    out there is going to get taken care of. So they require us to
    have 24/7 availability in an integrated EMS system.
         It is very difficult to get that kind of data. We
    certainly look for the patients who need to be served that we
    can't reach in appropriate times, and we build the system to
    try to do that. That is why we put in IFR. That is why we put
    in NVG. That is why building an IFR infrastructure is so
    important. But there is a balance that we have to do; not put
    pressure on the pilot, find another way. But the only way you
    can do that is to have a fully integrated EMS system from top
    to bottom, with the air medicine part of that fully integrated
    within the regulation.
        Mr. Costello. Mr. Yale, did you want to comment?
        Mr. Yale. I would echo the comments that have just been
    made, but add to it that it is a balancing act that we need to
    look at when we deal with the requests that you were talking
    about. There is both a risk benefit and a cost benefit that
    needs to be looked at and the ability to be able to respond. It
    is important that we build systems that are capable of meeting
    the need in our area; that we build systems that have the
    ability to sustain that ability to meet that need; and that we
    do it in the safest way possible. But I think that the real
    critical component to pull away from this, as Matt suggested,
    is that we need to recognize that, when it comes to the
    transportation of the patient, we need to deal with that from a
    decision can we go, pick up that patient, and bring them and
    the crew back safely and complete that mission. If we think we
    are taking a risk in putting that patient or our crew in harm's
    way to do it, then we are making a mistake.
        Mr. Costello. Ms. Frazer?
        Ms. Frazer. Yes. We do have a standard that says the pilot
    should be insulated from the decision-making that has anything
    to do with the patient, and typically what we were trying to
    insulate the pilot from are things like there is a child--which
    typically brings a lot of emotion--that really needs our help.
    So the decision-making of the pilot is totally based on the
    aviation, weather things, not anything to do with the patient.
    It is not always possible, but as much as possible, keep him
    insulated from the patient information.
        Mr. Costello. Very good. We may have a few other questions
    that other Members have submitted that we will be submitting to
    you in writing to answer. The Chair thanks all of you for
    taking the time to be with us today to offer your perspective
    and your suggestions on this important topic.
        As I said in the beginning, the purpose of the hearing was
    to have an opportunity for government and industry and the
    health care community to discuss this important issue and to
    try and figure out how we can enhance helicopter EMS safety,
    and I think we have had a very good hearing today. We have
    heard different perspectives and different viewpoints as to how
    we get where we all need to be, and I assure you, Ms. Friedman
    and others, that we are not going to stop here; that we are
    going to work with Mr. Altmire, we are going to work with Mr.
    Salazar and others concerning their legislation to see how we
    can go from where we are today to enhancing EMS helicopter
    safety.
        So, again, we thank you for being here, for offering your
    testimony. You may receive some written questions in the mail
    from us to respond to, but that concludes our hearing. Thank
    you.
        [Whereupon, at 12:39 p.m., the Subcommittee was adjourned.]

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