[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

                               ----------
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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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