    Aviation Safety: Improved Data Collection Needed for Effective
    Oversight of Air Ambulance Industry (21-FEB-07, GAO-07-353).

    Air ambulance transport is widely regarded as improving the
    chances of survival for trauma victims and other critical
    patients. However, in recent years, the number of air ambulance
    accidents has led to increased industry scrutiny by government
    agencies, the public, the media, and the industry itself. The
    Federal Aviation Administration (FAA), which provides safety
    oversight, has been called upon by the National Transportation
    Safety Board (NTSB) and others to issue more stringent safety
    requirements for the industry. GAO's study addressed (1) recent
    trends in the air ambulance industry, (2) FAA's challenges in
    providing safety oversight, and (3) FAA's efforts to address the
    challenges and what is known about the effects of these efforts.
    To address these issues, we analyzed FAA, NTSB, and industry
    data, interviewed federal and industry officials, and conducted
    five site visits, among other things.
    -------------------------Indexing Terms-------------------------
    REPORTNUM:   GAO-07-353
        ACCNO:   A66084
      TITLE:     Aviation Safety: Improved Data Collection Needed for
    Effective Oversight of Air Ambulance Industry
         DATE:   02/21/2007
      SUBJECT:   Air transportation
    	     Aircraft accidents
    	     Aircraft industry
    	     Aircraft safety
    	     Data collection
    	     Emergency medical services
    	     Federal regulations
    	     Helicopters
    	     Inspection
    	     Performance measures
    	     Risk assessment
    	     Safety standards
    	     Transportation industry
    	     Transportation safety
    	     Government agency oversight

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    GAO-07-353

         * [1]Results in Brief
         * [2]Background

              * [3]Air Ambulance Operations Perform Various Duties and Take Sev
              * [4]Government and Industry Both Play a Role in Air Ambulance Ov

         * [5]Increase in Size and Safety-Related Concerns Mark Industry's

              * [6]Data Limitations Preclude Complete Understanding of Industry
              * [7]Growth Is Primarily in Stand-Alone Businesses and Has Led to
              * [8]Increase in Number of Accidents Has Led to Greater Industry

         * [9]FAA Safety Oversight Does Not Fully Address Industry's Opera

              * [10]Air Ambulance Operations Face Risks Different from Those Fac
              * [11]FAA Inspections Framework Is Not Tailored to Risks of the Ai
              * [12]Part 135 Regulations Do Not Address Specific Dangers Inheren

         * [13]FAA Efforts to Improve Safety Are Under Way, but Effects Are

              * [14]FAA Efforts Targeted at Improving Air Ambulance Safety Overs

                   * [15]FAA Guidance Focuses on Identified Safety Concerns
                   * [16]Additional FAA Resources Allocated to Air Ambulance
                     Oversigh
                   * [17]FAA Has Increased Collaboration with the Industry

              * [18]FAA Lacks an Approach for Evaluating the Effects of Its Effo

         * [19]Conclusions
         * [20]Recommendations for Executive Action
         * [21]Agency Comments and Our Evaluation
         * [22]GAO Contact
         * [23]Staff Acknowledgments
         * [24]GAO's Mission
         * [25]Obtaining Copies of GAO Reports and Testimony

              * [26]Order by Mail or Phone

         * [27]To Report Fraud, Waste, and Abuse in Federal Programs
         * [28]Congressional Relations
         * [29]Public Affairs

    Report to the Chairman, Subcommittee on Aviation, Committee on
    Transportation and Infrastructure, House of Representatives

    United States Government Accountability Office

    GAO

    February 2007

    AVIATION SAFETY

    Improved Data Collection Needed for Effective Oversight of Air Ambulance
    Industry

    GAO-07-353

    Contents

    Letter 1

    Results in Brief 3
    Background 5
    Increase in Size and Safety-Related Concerns Mark Industry's Recent Years
    13
    FAA Safety Oversight Does Not Fully Address Industry's Operational Risks
    23
    FAA Efforts to Improve Safety Are Under Way, but Effects Are Not Being
    Measured 33
    Conclusions 40
    Recommendations for Executive Action 41
    Agency Comments and Our Evaluation 41
    Appendix I Scope and Methodology 43
    Appendix II NTSB Air Ambulance Accident Data 48
    Appendix III Comments from the Association of Air Medical Services 55
    Appendix IV GAO Contact and Staff Acknowledgments 61

    Tables

    Table 1: Examples of Independent and Hospital-Based Operators 9
    Table 2: Examples of Air Ambulance Industry Initiatives to Address Safety
    Concerns 22
    Table 3: Key FAA Published Efforts to Improve Air Ambulance Safety 34
    Table 4: NTSB Recommendations and FAA Responses 38
    Table 5: Industry and Trade Organizations Interviewed 43
    Table 6: Description of States Selected for Site Visits 46
    Table 7: NTSB Air Ambulance Accident Information, 1998 through 2005 48

    Figures

    Figure 1: Air Ambulance Helicopter 2
    Figure 2: Helicopter Air Ambulance Service Locations 7
    Figure 3: Air Ambulance Scene Response Flight Legs 11
    Figure 4: Annual Air Ambulance Bases and Aircraft, 2003 to 2005 15
    Figure 5: Number of Hospital-Based and Airport and Helipad Air Ambulance
    Bases, 2003 to 2005 18
    Figure 6: Total Air Ambulance Accidents, 1998 to 2005 21
    Figure 7: Time of Day of Air Ambulance Fatal and Nonfatal Accidents, 1998
    to 2005 25
    Figure 8: Percentage of Air Ambulance and Other Helicopter Accidents
    Associated with Adverse Weather, 1998 to 2005 26

    Abbreviations

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

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

    United States Government Accountability Office

    Washington, DC 20548

    February 21, 2007

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

    Dear Mr. Chairman:

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

    Figure 1: Air Ambulance Helicopter

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

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

    Results in Brief

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

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

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

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

    Background

    Air Ambulance Operations Perform Various Duties and Take Several Forms

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

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

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

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

    Figure 2: Helicopter Air Ambulance Service Locations

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

               o In a hospital-based model, a hospital typically provides the
               medical services and staff and contracts with an aviation services
               provider for pilots, mechanics, and aircraft. The aviation
               services provider also holds the FAA operating certificate. In the
               hospital-based model, the hospital is responsible for billing the
               patient and pays the operator on a fixed monthly and variable
               hourly rate for services provided.^4
               o In a stand-alone (independent) provider model, an independent
               operator sets up a base in a community and serves various
               facilities and localities. Typically, the operator holds the FAA
               operating certificate and employs both the medical and flight
               crews, or contracts with an aviation services provider for all of
               these things. Compared with the hospital-based model, this
               approach carries more financial risk for the operator because
               revenues depend solely on patient flights.

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

               Table 1: Examples of Independent and Hospital-Based Operators

    Characteristic       Independent operator          Hospital-based operator
    Program              Petroleum Helicopters         Teddy Bear Transport
                            International Air Medical
                                                          Cook Children's Medical
                                                          Center
    Holder and location  Petroleum Helicopters         CJ Systems; Harrisburg,
    of FAA operating     International (PHI);          Pennsylvania
    certificate          Lafayette, Louisiana
    Number of bases      49                            1
    Location of bases    14 states                     Fort Worth, Texas
    Number of            224                           1
    helicopters
    Tax status           For profit                    Nonprofit
    Flight crew employer PHI                           CJ Systems
    Medical crew         PHI                           Cook Children's Medical
    employer                                           Center
    Revenue sources      Per-flight basis              Patient flights,
                                                          hospital admission
    Mission profile      50% on-scene 50%              100%
                            hospital-to-hospital          hospital-to-hospital

               Source: GAO.

    			  Government and Industry Both Play a Role in Air Ambulance
    			  Oversight

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

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

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

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

               Figure 3: Air Ambulance Scene Response Flight Legs

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

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

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

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

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

    			  Data Limitations Preclude Complete Understanding of Industry�s
    			  Growth

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

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

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

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

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

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

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

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

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

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

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

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

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

               o Call jumping: Industry officials reported that call jumping
               occurs when an air ambulance operator responds to a scene to which
               that operator was not dispatched or when multiple operators are
               summoned to an accident scene. This situation is potentially
               dangerous because the aircraft are all operating in the same
               uncontrolled airspace--often during nighttime or in marginal
               weather conditions--increasing the risk of a midair collision or
               other accident. The term "call jumping" originated in the 1970s
               when some ground ambulance services were involved in a similar
               practice.
               o Inappropriate use of air medical aircraft: One industry official
               has posited that air medical helicopter use may be excessive,
               unsafe, and not beneficial for most patients, citing recent
               studies that conclude few air transport patients benefited
               significantly over patients transported by ground and the recent
               increase in the number of air medical accidents. Other studies
               have disagreed with this position, citing air ambulances' impact
               on reductions in mortality by quickly transporting critically
               injured patients.

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

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

               Figure 6: Total Air Ambulance Accidents, 1998 to 2005

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

    ^18Balanced Budget Act of 1997, P.L. No. 105-33, S 4523 (Aug. 5, 1997).

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

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

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

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

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

    Year      Organization             Initiative
    1999      AAMS                     Distributed a safety poster to its
                                          members and held "Safety Day" at the
                                          Air Medical Transport Conference to
                                          focus on program safety.
    2000      Air Medical Safety       Develops recommended practices for the
                 Advisory Council (AMSAC) industry.
    2001/2002 AMSAC                    Implemented "Train the Trainer" Air
                                          Medical Resource Management programs.
    2002      Air Medical Physicians   Published "A Safety Review and Risk
                 Association              Assessment in Air Medical Transport."
    2005      AAMS                     Adopted "Vision Zero," the air medical
                                          community's program to promote safety
                                          awareness.
    2006      AAMS                     Sponsors the Flight Operational
                                          Database for Air Medical Services--an
                                          effort to collect flight and
                                          flight-hour data for air medical
                                          operators.
    2006      Air & Surface Transport  Published a position paper on transport
                 Nurses Association       nurse safety in the transport
                                          environment.

    Source: GAO.

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

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

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

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

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

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

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

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

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

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

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

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

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

               o Multiple bases located away from headquarters. FAA inspectors
               assigned to large air ambulance certificates told us that the
               dispersion of bases away from operator headquarters may result in
               less disciplined adherence to internally established risk
               assessment practices and protocols. Air ambulance bases are often
               dispersed away from headquarters, either as independent
               stand-alone bases or through contractual relationships with
               hospitals. In contrast, other Part 135 helicopter operations
               typically are not dispersed. The dispersion of bases away from the
               certificate holders' headquarters and the location of bases are in
               part due to medical need and demand for services. For example, one
               state emergency medical services official reported that operators
               look at high accident road intersections in considering where to
               locate their bases.
               o Many individuals and systems are involved in transports. Many
               individuals and systems may be involved in coordinating air
               ambulance transports. The number and expertise of people involved
               in making decisions and passing on information about flights and
               flight conditions can increase the risk of incorrect or incomplete
               information being relayed. Multiple systems, involving both public
               and private resources, are used in determining when to relay a
               request, which air ambulance provider the request will be relayed
               to, and if a request will be accepted and completed. Emergency
               medical service dispatchers may not uniformly gather all of the
               information needed by air ambulance providers, such as weather at
               the landing site. Ground personnel may also be involved with
               relaying critical information about the landing site to the crew;
               but again, they may not provide critical information to the air
               ambulance operator. For example, in Parumph, Nevada, an air
               ambulance helicopter crashed while attempting to pick up a patient
               at a remote site when ground personnel incorrectly informed the
               helicopter crew that there were no wires obstructing the site.
               o Human judgment may override risk-based protocols. Human judgment
               can play a critical role in air ambulance transport, particularly
               given the risks found in the flight environment and the medical
               urgency. For example, during a dark night in June 1998 in La
               Gloria, Texas, a helicopter crashed into trees nearly 20 miles
               past the accident site to which it was headed. Attributes of the
               crash, as reported by NTSB, indicated that the pilot failed to
               recognize his intended destination and had flown past it and that
               the adverse weather conditions resulted in the pilot's loss of
               control from experiencing spatial disorientation. The pressure to
               complete the airlift and the pilot's lack of experience with
               flying by instruments were cited among the contributing factors by
               NTSB in its accident report. The following accident data highlight
               the prominence of poor human judgment in an already inherently
               risky line of work:

                            o Ninety-four percent of air ambulance accidents
                            between 1998 and 2005 had at least one cause related
                            to pilot/operational errors, while 86 percent of
                            non-air-ambulance accidents during the same time
                            period had pilot/operational causes.
                            o In total, 28 percent of air ambulance accidents
                            between 1998 and 2005 had at least one planning or
                            decision-making related cause, while 19 percent of
                            non-air-ambulance accidents had such causes.

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

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

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

               o Size and scope of air ambulance operations. Each year, the
               National Flight Standards Work Program Guidelines sets the minimum
               number of FAA required inspections for all Part 135 operators.
               Although the National Flight Standards Work Program Guidelines
               outlines the minimum inspection requirements for all Part 135
               operators, the principal inspectors must determine how many
               additional inspections might be necessary for adequate oversight
               in light of the size and risk factors associated with a
               certificate holder. In the case of large air ambulance operators,
               these additional inspections can be considerable due to the size
               and scope of the operations. For example, according to FAA
               officials, the certificate management team for one large air
               ambulance operator had 2,396 hours of required inspector
               surveillance hours for fiscal year 2006. However, the team
               estimates that a total of 4,425 inspector surveillance hours will
               actually be needed for fiscal year 2006 in order to provide
               appropriate oversight. Additionally, FAA's procedures for
               establishing and maintaining pay grades for inspectors may be a
               contributing factor in how much attention is given to the
               oversight of large air ambulance operators. FAA assigns points to
               the inspection activities of inspectors, and these points, in
               turn, are tied to an inspector's pay. Several inspectors of air
               ambulance operators reported that the points assigned to the
               oversight of these operators are not commensurate with the risk
               and size of these operations.
               o Lack of training and qualifications to oversee use of
               technology. According to FAA inspectors and officials we spoke
               with, FAA has few inspectors who have the necessary qualifications
               to certify the use of safety technology being adopted by air
               ambulance operators, and FAA does not provide inspectors with
               training in emerging safety technology. Several of the FAA
               inspectors we interviewed reported not receiving what they felt to
               be the necessary training that would allow them to provide
               oversight of operators' implementation of new technology. This is
               similar to concerns we raised in a previous report on FAA's
               inspection program.^28 Specifically, we found that FAA develops
               technical courses on an ad-hoc basis rather than part of an
               overall curriculum for each inspector specialty--such as air
               ambulance operations--because the agency has not systematically
               identified the technical skills and competencies each type of
               inspector needs to effectively perform inspections. FAA developed
               the Flight Standards Inspector Resource Program, in which
               inspectors with special expertise in a technology can assist other
               inspectors whose operator may be using such technology. For
               example, currently few inspectors are qualified to provide
               operator certification in night vision goggle use. However,
               several inspectors we spoke to found this program problematic,
               because of the burden it poses to the inspector that must certify
               the use of night vision goggles and continue to carry out their
               other required duties.
               o Limited oversight of base locations. While air ambulance bases
               and helicopters for any one operator are often located across the
               country, the assigned principal inspectors are based in the FAA
               district office where the operating certificate is registered and
               held by an operator's headquarters office. This may be important
               because operators may have many remote bases of operations; for
               example, one of the largest air ambulance companies has no
               helicopters located at the headquarters location. FAA principal
               inspectors assigned to large air ambulance certificates we spoke
               with said they did not have the travel funds or time to perform
               inspections of many remote bases. Instead, inspectors from local
               FAA offices--called geographic inspectors--assist with the
               oversight of these bases at the request of a principal
               inspector.^29 Some FAA principal inspectors expressed little
               confidence in the quality of these inspections, however, because
               geographic inspectors may lack comprehensive knowledge of the
               operators' manuals or lack helicopter expertise.

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

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

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

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

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

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

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

    			  FAA Guidance Focuses on Identified Safety Concerns

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

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

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

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

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

    ^28GAO, Aviation Safety: FAA Management Practices for Technical Training
    Mostly Effective; Further Actions Could Enhance Results, [30]GAO-05-728
    (Washington, D.C.: Sept. 7, 2005).

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

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

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

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

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

    Date         Type of action      Title              Purpose
    January 2005 Notice 8000.293 (on Helicopter         Provides guidance for
                    Jan. 28, 2006,      Emergency Medical  FAA safety inspectors
                    became permanent    Service Operations to help operators
                    through Safety                         review pilot and
                    Alert for Operators                    mechanic
                    06001)                                 decision-making
                                                           skills, procedural
                                                           adherence, and crew
                                                           resource management
                                                           practices.
    August 2005  Notice 8000.301     Operational Risk   Provides guidance to
                                        Assessment         FAA inspectors to
                                        Programs for       promote improved risk
                                        Helicopter         assessment programs
                                        Emergency Medical  and risk management
                                        Services           tools and training to
                                                           all flight crews,
                                                           including medical
                                                           staff.
    September    Notice 8000.307     Special Emphasis   Provides guidance to
    2005                             Inspection Program FAA safety inspectors
                                        for Helicopter     of air ambulance
                                        Emergency Medical  operators to place
                                        Services           emphasis on specific
                                                           areas, including
                                                           operational control
                                                           (policies, procedures,
                                                           training, etc), safety
                                                           culture development,
                                                           access to weather
                                                           information,
                                                           operators' knowledge
                                                           of geographic area,
                                                           etc.
    September    Advisory Circular   Air Medical        Provides guidance to
    2005         00-64               Resource           operators to establish
                                        Management         minimum training
                                                           guidelines for all air
                                                           medical team members.
    January 2006 Flight Standards    Helicopter         Provides information
                    Handbook Bulletin   Emergency Medical  to inspectors about
                    for Air             Services Loss of   pilot training and
                    Transportation,     Control and        checking standards and
                    06-02               Controlled Flight  requires a review of
                                        into Terrain       air ambulance operator
                                        Accident Avoidance training programs.
                                        Programs
    January 2006 Flight Standards    Helicopter         Provides guidance to
                    Handbook Bulletin   Emergency Medical  principal operations
                    for Air             Services; OpSpec   inspectors about
                    Transportation,     A021/A002          revisions to the
                    06-01               Revisions          weather minimums for
                                                           air ambulance
                                                           operators.
    March 2006   Notice 8000.318     Public Helicopter  Provides guidance to
                                        Emergency Medical  inspectors to ensure
                                        Services           that public air
                                        Operations         ambulance operators
                                                           are aware of current
                                                           FAA policies and
                                                           standards for air
                                                           ambulance operations,
                                                           and to emphasize the
                                                           importance of public
                                                           aircraft operators'
                                                           compliance with these
                                                           operating rules.
    August 2006  Aeronautical        Helicopter Night   Provides information
                    Information Manual  Visual Flight Rule and guidance
                                        Operations         concerning night
                                                           celestial and man-made
                                                           lighting on seeing
                                                           conditions in night
                                                           visual flight rule
                                                           operations.
    August 2006  Aeronautical        Landing Zone       Provides information
                    Information Manual  Information        and guidance on the
                                                           selection of ad-hoc
                                                           helicopter landing
                                                           sites by ground
                                                           responders and the use
                                                           of such sites by
                                                           helicopter operators.
    November     Notice 8000.333     [32]Helicopter     Provides information
    2006                             Emergency Medical  and guidance to
                                        Services (HEMS)    principal inspectors
                                        use of the         on the use of the
                                        Aviation Digital   ceiling and visibility
                                        Data Service       tool developed as a
                                        (ADDS)             result of the 2006
                                        Experimental HEMS  Weather Summit.
                                        Tool

    Source: FAA.

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

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

      Additional FAA Resources Allocated to Air Ambulance Oversight

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

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

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

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

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

      FAA Has Increased Collaboration with the Industry

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

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

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

    Table 4: NTSB Recommendations and FAA Responses

    NTSB recommendation to FAA      FAA response
    Require all air ambulance       FAA is looking at options to address
    operators to comply with Part   concerns about the differences in the
    135 operations specifications   flight rules--specifically the weather
    during the conduct of all       minimums--through new weather reporting
    flights with medical personnel  requirements and the application of
    on board.                       "eligible on demand" standards to air
                                       ambulance helicopter operations.
    Require all air ambulance       FAA has implemented this recommendation
    operators to develop and        with the publication of Notice 8000.301.
    implement flight risk
    evaluation programs.
    Require air ambulance           FAA has a study under way to identify best
    operators to use formalized     industry practices in ground communication
    dispatch and flight-following   and dispatch to support effective FAA
    procedures.                     requirements and policy.
    Require air ambulance           FAA has emphasized the strategic avoidance
    operators to install terrain    of controlled flight into terrain
    awareness and warning systems   accidents in Flight Standards Handbook
    on their aircraft and to        Bulletin for Air Transportation, 06-02. At
    provide adequate training to    FAA request, RTCA Inc., a private
    ensure that flight crews are    corporation, has formed a special
    capable of using the systems.   committee to develop the minimum
                                       operational standards for helicopter
                                       terrain awareness and warning systems,
                                       which will be used by FAA in developing
                                       future requirements.

    Sources: NTSB and FAA.

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

    FAA Lacks an Approach for Evaluating the Effects of Its Efforts

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

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

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

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

    Conclusions

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

    Recommendations for Executive Action

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

               o Identify the data necessary to better understand the air
               ambulance industry and develop a systematic approach for gathering
               and using this data. At a minimum, this data should include the
               number of flights and flight hours, the number and locations of
               air ambulance helicopters, and the number and types of FAA
               violations and enforcement actions related to the air ambulance
               fleet.
               o Collect information on the implementation of voluntary FAA
               guidance by air ambulance operators and evaluate the effectiveness
               of that guidance.

    			  Agency Comments and Our Evaluation

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

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

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

               Sincerely yours,

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

    			  Appendix I: Scope and Methodology

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

               Table 5: Industry and Trade Organizations Interviewed

               Source: GAO.

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

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

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

               To learn more about air ambulance safety risks and concerns, we
               conducted a total of five site visits of air ambulance providers
               in Arizona, California, Maryland, Texas, and Washington. We chose
               these states based on the presence of a large air ambulance
               market,^2 state accreditation requirements, or an operating public
               provider. To have access to a greater number of providers
               representing a variety of business models, operational
               characteristics, and accident histories, we narrowed our possible
               site visit locations to large air ambulance markets. To examine
               the relevance and describe the extent of state accreditation
               requirements, we included states with and without these
               requirements. Lastly, to learn about the policies and practices
               public providers may be engaged in that impact safety, we chose
               states that had a public operator.

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

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

    ^1There is no clear consensus about what constitutes an air ambulance
    accident; thus, other studies may present different accident totals
    covering the same time period.

    ^2Large air ambulance markets were determined by state using the total
    number of bases and aircrafts as identified in the Atlas and Database of
    Air Medical Services. After states had been identified as having the
    greatest number of bases and aircrafts, metropolitan regions were chosen
    on the basis of having the greatest number of operators present in the
    area.

    Table 6: Description of States Selected for Site Visits

                  Description of air ambulance
    State      market                        Description of programs visited
    Arizona    Providers: 10                    o Native Air, a subsidiary of
                                                   Omniflight Helicopters, is a
                  Helicopters: 50                  community-based operator, and
                                                   its fleet is composed of 15
                  Accidents, 1998 to 2005: 8       helicopters located at 12
                                                   bases in Arizona and Montana.
                  State requirements: The state
                  requires licensing for all
                  air ambulance providers
                  through the Arizona
                  Department of Health
                  Services. Inspection and
                  registration for all air
                  ambulance units operating in
                  Arizona is required on a
                  yearly basis. If a provider
                  is accredited by the
                  Commission on Accreditation
                  of Medical Transport Systems
                  (CAMTS), the state
                  requirement for a licensure
                  inspection is waived.
    California Providers: 28                    o The FlightCare Program at
                                                   Enloe Medical Center is a
                  Helicopters: 72                  nonprofit hospital-based
                                                   program. The program's fleet
                  Accidents, 1998 to 2005: 7       consists of one helicopter
                                                   based at the Enloe Hospital
                  State requirements: The state    helipad.
                  of California has delegated      o REACH is an independent
                  authority to local               for-profit air ambulance
                  governments for emergency        provider. The company has
                  medical services (EMS).          seven helicopters and nine
                  County governments are           bases in California and
                  responsible for coordinating     Oregon.
                  emergency medical services,      o CALSTAR is a nonprofit
                  including the coordination       community-based program. The
                  and monitoring of air            company's fleet consists of 11
                  ambulance services.              helicopters and seven bases in
                                                   California.
                                                   o The California Highway
                                                   Patrol operates as an air
                                                   rescue provider. The
                                                   California Highway Patrol
                                                   maintains a fleet of 14
                                                   helicopters, 11 of which are
                                                   partially used for medical
                                                   emergency transport and air
                                                   rescue. These helicopters are
                                                   based at nine locations
                                                   throughout the state.
    Maryland   Providers: 3                     o The Maryland State Police
                                                   Aviation Command is a public
                  Helicopters: 18                  provider and has a fleet of 12
                                                   helicopters based in eight
                  Accidents, 1998 to 2005: 1       locations across the state.

                  State requirements: Maryland
                  requires private providers of
                  air ambulance services
                  operating in the state to be
                  licensed by the state and
                  CAMTS accredited.
    Texas      Providers: 23                    o Teddy Bear Transport of Cook
                                                   Children's Medical Center is a
                  Helicopters: 61                  hospital-based program that
                                                   conducts hospital-to-hospital
                  Accidents, 1998 to 2005: 13      transports for pediatric
                                                   patients. The program
                  State requirements: The state    contracts with a vendor for
                  requires air ambulances and      its aviation services and
                  providers to be licensed by      operates one helicopter.
                  the Texas Department of State    o PHI Air Medical is an
                  Health Services. The             independent program conducting
                  licensure process requires       a mix of scene response and
                  providers to submit a copy of    hospital-to-hospital
                  their current FAA operational    transports. PHI's programs in
                  certification that includes      Texas include 12 helicopters
                  designation for air ambulance    stationed at 12 bases. In
                  operations.                      total, the company has 224 air
                                                   ambulance helicopters
                                                   stationed at 49 bases in 14
                                                   states.
    Washington Providers: 2                     o Airlift Northwest is a
                                                   nonprofit community-based
                  Helicopters: 10                  program. The program contracts
                                                   out its aviation services. Its
                  Accidents, 1998 to 2005: 3       fleet consists of six
                                                   helicopters stationed at four
                  State requirements: The state    bases in Washington.
                  requires providers and air
                  ambulances to be licensed
                  through the Washington
                  Department of Health.
                  Providers must be accredited
                  by CAMTS. Air ambulance
                  licensure applicants must
                  affirm in the application
                  that their service meets all
                  FAA regulations, and they
                  must also provide a copy of
                  their current FAA certificate
                  and operational
                  specifications.

    Source: GAO.

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

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

    Appendix II: NTSB Air Ambulance Accident Data

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

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

                                 Number of
                        When     fatalities,
                Flight  accident injuries, or
    Year regulation  occurred uninjured     State Accident details
    1998        135  Night    4 fatalities  UT    An air ambulance helicopter
                                                     transporting an injured
                                                     skier to a hospital was
                                                     destroyed when it collided
                                                     with mountainous terrain
                                                     after flying into known
                                                     adverse weather.
    1998         91  Day      3 injuries    AR    An air ambulance helicopter
                                                     en route to pick up a
                                                     patient from a hospital was
                                                     substantially damaged during
                                                     a hard landing following a
                                                     loss of engine power.
    1998         91  Night    3 fatalities  TX    An air ambulance helicopter
                                                     en route to an accident
                                                     scene collided with terrain
                                                     and trees after encountering
                                                     poor visibility conditions.
    1998         91  Night    3 uninjured   CA    An air ambulance helicopter
                                                     was destroyed when it rolled
                                                     over while attempting to
                                                     land at a makeshift landing
                                                     zone near an accident site.
    1998         91  Night    3 fatalities  IA    Due to faulty components, an
                                                     air ambulance helicopter
                                                     experienced an in-flight
                                                     breakup during descent and
                                                     was destroyed.
    1998        135  Night    4 uninjured   ID    An air ambulance helicopter
                                                     taking off from an off-site
                                                     landing zone sustained
                                                     substantial damage when it
                                                     collided with wires.
    1999         91  Night    3 injuries    OH    An air ambulance helicopter
                                                     en route to pick up a
                                                     patient from a hospital was
                                                     destroyed when it impacted a
                                                     house after the pilot
                                                     inadvertently entered snowy
                                                     conditions.
    1999        135  Day      5 uninjured   TX    An air ambulance helicopter
                                                     transporting a patient to a
                                                     hospital from an accident
                                                     scene was substantially
                                                     damaged when it impacted
                                                     power lines during takeoff.
    1999         91  Night    3 fatalities  NV    An air ambulance helicopter
                                                     returning to base after
                                                     transporting a patient to a
                                                     hospital was destroyed after
                                                     encountering deteriorating
                                                     weather conditions and
                                                     colliding with terrain.
    1999         91  Day      3 uninjured   FL    An air ambulance helicopter
                                                     en route to pick up a
                                                     patient collided with a
                                                     building while hovering in
                                                     preparation for takeoff.
    1999         91  Day      1 uninjured   MO    An air ambulance helicopter
                                                     impacted terrain (during
                                                     takeoff from a helipad
                                                     located on top of a
                                                     hospital) because an
                                                     auxiliary power line was
                                                     still attached to the
                                                     helicopter.
    1999         91  Night    3 injuries    FL    An air ambulance helicopter
                                                     crashed when approaching an
                                                     off-site landing zone to
                                                     pick up a patient.
    1999        135  Day      4 uninjured   MT    An air ambulance helicopter
                                                     collided with a tower during
                                                     takeoff from a remote site.
    2000         91  Night    3 uninjured   TN    An air ambulance helicopter
                                                     was substantially damaged
                                                     when it collided with a tree
                                                     while attempting to land at
                                                     a roadside landing zone.
    2000        135  Night    4 fatalities  TX    An air ambulance helicopter
                                                     transporting a patient to a
                                                     hospital was destroyed when
                                                     it impacted terrain after
                                                     flying into known adverse
                                                     weather conditions.
    2000         91  Day      2 uninjured   MN    An air ambulance helicopter
                                                     returning from dropping off
                                                     a patient was substantially
                                                     damaged from an in-flight
                                                     collision with a warehouse.
    2000         91  Day      3 fatalities  FL    An air ambulance helicopter
                                                     traveling back to base after
                                                     completing an interfacility
                                                     transport collided with a
                                                     radio transmission tower and
                                                     was destroyed.
    2000         91  Night    3 uninjured   TX    An air ambulance helicopter
                                                     was substantially damaged
                                                     when the tail rotor
                                                     contacted trees while
                                                     attempting to land at an
                                                     accident site.
    2000         91  Night    3 fatalities  GA    An air ambulance helicopter
                                                     returning to base was
                                                     destroyed when it collided
                                                     with trees and the ground
                                                     during flight.
    2000         91  Day      1 uninjured   MN    An air ambulance helicopter
                                                     departing for refueling was
                                                     substantially damaged during
                                                     takeoff from a hospital
                                                     helipad during windy
                                                     conditions.
    2000        135  Day      4 injuries    AZ    An air ambulance helicopter
                                                     attempting to airlift a
                                                     seriously injured patient
                                                     impacted trees and terrain
                                                     and was substantially
                                                     damaged.
    2000         91  Night    1 fatality    NC    An air ambulance helicopter
                                                     experiencing mechanical
                                                     difficulties collided with
                                                     terrain and was destroyed.
                                                     The accident occurred after
                                                     a mechanic had taken
                                                     insufficient action to fix
                                                     the problem.
    2000         91  Night    3 uninjured   NV    An air ambulance helicopter
                                                     attempting to pick up a
                                                     patient at a remote site
                                                     collided with the ground
                                                     during an aborted landing
                                                     and sustained substantial
                                                     damage.
    2000         91  Night    3 injuries    AZ    An air ambulance helicopter
                                                     on a positioning flight
                                                     sustained substantial damage
                                                     when the pilot became ill
                                                     and lost control just before
                                                     landing.
    2001         91  Night    1 injury,     IL    An air ambulance helicopter
                                                     readying for takeoff
                                 2 uninjured         received minor damage when a
                                                     hospital security guard
                                                     walked into the tail rotor.
    2001         91  Day      1 fatality    CO    An air ambulance helicopter
                                                     conducting a postmaintenance
                                                     flight check was destroyed
                                                     when it impacted the ground
                                                     after losing rotor speed.
    2001         91  Day      2 injuries    NY    An air ambulance helicopter
                                                     on a positioning flight was
                                                     substantially damaged during
                                                     a precautionary landing
                                                     following a mechanical
                                                     malfunction.
    2001         91  Day      3 uninjured   WY    An air ambulance helicopter
                                                     conducting an off-site
                                                     landing was substantially
                                                     damaged when its tail rotor
                                                     impacted a barrel.
    2001         91  Day      3 uninjured   AZ    An air ambulance helicopter
                                                     on a positioning flight was
                                                     substantially damaged during
                                                     a forced landing following a
                                                     reported loss of engine
                                                     power.
    2001        135  Day      4 uninjured   OR    An air ambulance helicopter
                                                     departing an off-site
                                                     landing zone had to conduct
                                                     an emergency landing because
                                                     of a fire in the aircraft.
    2001         91  Day      3 injuries    TX    An air ambulance helicopter
                                                     en route to pick up a
                                                     patient was substantially
                                                     damaged when it impacted
                                                     trees and terrain following
                                                     a loss of engine power.
    2001        135  Day      4 uninjured   CA    An air ambulance helicopter
                                                     encountering low visibility
                                                     conditions rolled onto its
                                                     side during takeoff from a
                                                     remote location.
    2001         91  Night    1 fatality,   CA    An air ambulance helicopter
                                                     attempting to land at an
                                 1 injury,           off-site landing zone was
                                                     destroyed when it
                                 1 uninjured         encountered brownout
                                                     conditions and collided with
                                                     trees.
    2001         91  Night    2 injuries,   TX    An air ambulance helicopter
                                                     on a nighttime positioning
                                 1 uninjured         flight was substantially
                                                     damaged during a hard
                                                     landing following a total
                                                     loss of engine power.
    2001         91  Night    1 injury      ID    An air ambulance helicopter
                                                     on a nighttime repositioning
                                                     flight was destroyed when it
                                                     collided with terrain after
                                                     the pilot became spatially
                                                     disoriented.
    2002         91  Night    2 fatalities, OH    An air ambulance helicopter
                                                     was destroyed when it
                                 1 injury            collided with a brick
                                                     fac,ade during a takeoff
                                                     from a rooftop helipad in
                                                     windy conditions.
    2002         91  Day      1 fatality,   CA    An air ambulance helicopter
                                                     en route to pick up a
                                 2 injuries          patient was substantially
                                                     damaged when the pilot
                                                     became visually disoriented
                                                     and collided with the
                                                     surface of a lake.
    2002         91  Night    3 uninjured   AR    An air ambulance helicopter
                                                     was substantially damaged
                                                     when its tail rotor struck
                                                     trees during an approach to
                                                     a landing zone.
    2002         91  Day      3 uninjured   FL    An air ambulance helicopter
                                                     experiencing mechanical
                                                     trouble was substantially
                                                     damaged when it performed a
                                                     forced landing.
    2002         91  Day      3 fatalities  NE    An air ambulance helicopter
                                                     en route to pick up a
                                                     patient was destroyed when
                                                     it experienced a loss of
                                                     control and a corresponding
                                                     collision with terrain.
    2002        135  Night    5 uninjured   FL    An air ambulance helicopter
                                                     transporting a patient had
                                                     an engine fire and was
                                                     forced to conduct an
                                                     emergency landing.
    2002         91  Day      4 injuries    FL    An air ambulance helicopter
                                                     en route to pick up a
                                                     patient collided with a
                                                     corner of a multistory
                                                     parking garage during
                                                     takeoff from a hospital
                                                     helipad.
    2002         91  Night    3 fatalities  CA    An air ambulance helicopter
                                                     en route to an accident
                                                     scene was destroyed after
                                                     impacting terrain while
                                                     maneuvering.
    2002        135  Night    4 fatalities  SD    An air ambulance helicopter
                                                     completing a nighttime
                                                     interfacility transport
                                                     crashed into terrain and was
                                                     destroyed after the pilot
                                                     lost control.
    2002         91  Day      3 uninjured   TX    An air ambulance helicopter
                                                     sustained substantial damage
                                                     following a loss of control
                                                     while attempting to take off
                                                     from a hospital helipad.
    2002         91  Day      1 uninjured   KY    An air ambulance helicopter
                                                     experiencing a loss of
                                                     control was substantially
                                                     damaged during an emergency
                                                     landing at an off-site
                                                     landing zone.
    2002        135  Day      4 uninjured   WA    An air ambulance helicopter,
                                                     while conducting an
                                                     interfacility transport,
                                                     sustained substantial damage
                                                     when it encountered whiteout
                                                     snow conditions and
                                                     completed a hard emergency
                                                     landing.
    2002         91  Night    3 uninjured   NY    An air ambulance helicopter
                                                     was substantially damaged
                                                     after encountering a gust of
                                                     wind during an engine
                                                     startup on a rooftop
                                                     helipad.
    2003         91  Night    2 fatalities, UT    An air ambulance helicopter
                                                     crashed into terrain after
                                 1 injury            encountering dense fog while
                                                     on an aborted mission to
                                                     pick up a patient.
    2003         91  Night    1 fatality    IL    An air ambulance helicopter
                                                     operating in reduced
                                                     visibility conditions was
                                                     destroyed as a result of a
                                                     collision with terrain.
    2003         91  Day      1 injury,     TX    An air ambulance helicopter
                                                     en route to pick up a
                                 2 uninjured         patient for interfacility
                                                     transport sustained
                                                     substantial damage when it
                                                     impacted terrain during a
                                                     hard landing.
    2003         91  Day      3 uninjured   TX    An air ambulance helicopter
                                                     was substantially damaged
                                                     after a tail rotor drive
                                                     failed during flight as a
                                                     result of a blanket coming
                                                     into contact with the tail
                                                     rotor blades due to an
                                                     unsecured cargo door.
    2003        135  Night    1 uninjured   MI    An air ambulance helicopter
                                                     at an off-site landing zone
                                                     was substantially damaged
                                                     when the tail rotor impacted
                                                     a roadway sign during an
                                                     aerial taxi.
    2003         91  Day      3 uninjured   PA    An air ambulance helicopter
                                                     conducted an emergency
                                                     landing because a flashlight
                                                     left on the tail boom came
                                                     into contact with the tail
                                                     rotor blades.
    2003         91  Day      1 fatality,   UT    An air ambulance helicopter
                                                     en route to its home base
                                 1 injury,           after completing a patient
                                                     transport was destroyed when
                                 1 uninjured         it impacted a hillside.
    2003        135  Day      3 injuries,   FL    An air ambulance helicopter
                                                     crashed while attempting to
                                 1 uninjured         take off from an off-site
                                                     landing zone.
    2003         91  Day      3 injuries    NY    An air ambulance helicopter
                                                     was substantially damaged
                                                     during a forced landing when
                                                     the pilot misinterpreted
                                                     power loss.
    2003        135  Day      4 uninjured   CA    An air ambulance helicopter
                                                     in the process of
                                                     transporting a patient made
                                                     an emergency off-airport
                                                     landing after experiencing
                                                     severe in-flight vibrations.
    2003         91  Night    3 uninjured   IL    An air ambulance helicopter
                                                     executed a precautionary
                                                     landing to a vacant parking
                                                     lot after the helicopter
                                                     encountered an in-flight
                                                     vibration.
    2003         91  Night    1 injury,     TX    An air ambulance helicopter
                                                     sustained substantial damage
                                 2 uninjured         when it impacted a safety
                                                     fence and rolled over during
                                                     an aborted takeoff following
                                                     a partial loss of engine
                                                     power.
    2003        135  Night    3 uninjured   IN    An air ambulance helicopter
                                                     sustained substantial damage
                                                     during a hard landing in a
                                                     gravel lot after losing
                                                     visibility due to dust.
    2003        135  Day      4 uninjured   AZ    An air ambulance helicopter
                                                     transporting a patient
                                                     experienced a loss of
                                                     control due to mechanical
                                                     failure and crashed on a
                                                     taxiway during an emergency
                                                     landing.
    2003         91  Day      1 injury      AR    An air ambulance helicopter
                                                     was substantially damaged
                                                     following a loss of control
                                                     during engine start because
                                                     the main rotor was still
                                                     tied down.
    2003         91  Night    3 uninjured   TX    An air ambulance helicopter
                                                     readying for an off-site
                                                     landing sustained
                                                     substantial damage when the
                                                     tail rotor blades impacted
                                                     trees while maneuvering.
    2003         91  Night    3 uninjured   KY    An air ambulance helicopter
                                                     landing at an off-site
                                                     landing zone was
                                                     substantially damaged when
                                                     its tail rotor struck a
                                                     hydrant that had not been
                                                     identified by ground
                                                     personnel.
    2003         91  Night    3 fatalities  CA    An air ambulance helicopter
                                                     on the way to pick up a
                                                     patient crashed into
                                                     mountainous terrain during
                                                     high winds and heavy rain.
    2004        135  Night    4 fatalities, TX    An air ambulance helicopter
                                                     transporting a patient
                                 1 injury            crashed into terrain while
                                                     maneuvering in reduced
                                                     visibility.
    2004        135  Night    1 fatality,   IN    An air ambulance helicopter
                                                     transporting a patient was
                                 3 injuries          substantially damaged when
                                                     it collided with terrain.
    2004         91  Day      3 uninjured   TX    An air ambulance helicopter
                                                     sustained substantial damage
                                                     when its tail rotor struck a
                                                     parked helicopter while
                                                     hovering prior to takeoff
                                                     from a helipad.
    2004         91  Day      3 uninjured   AZ    An air ambulance helicopter
                                                     landing at an off-site
                                                     landing zone was
                                                     substantially damaged after
                                                     a hard landing in low
                                                     visibility conditions.
    2004        135  Night    4 fatalities  SC    An air ambulance helicopter
                                                     flying in mist and light fog
                                                     collided with trees shortly
                                                     after picking up a patient
                                                     at an Interstate accident
                                                     site.
    2004        135  Day      4 uninjured   ID    An air ambulance helicopter
                                                     was substantially damaged
                                                     while maneuvering at an
                                                     accident site during windy
                                                     conditions.
    2004        135  Night    5 fatalities  NV    An air ambulance helicopter
                                                     crashed into mountainous
                                                     terrain at night and in
                                                     deteriorating weather
                                                     conditions.
    2004         91  Night    1 injury      NM    An air ambulance helicopter
                                                     on a positioning flight was
                                                     substantially damaged after
                                                     liftoff when the
                                                     helicopter's skid struck the
                                                     helipad and caused the
                                                     helicopter to roll over.
    2004         91  Night    3 fatalities  FL    An air ambulance helicopter
                                                     attempting to return to base
                                                     after abandoning a mission
                                                     due to bad weather was
                                                     destroyed when it crashed
                                                     into water.
    2004         91  Day      3 uninjured   AZ    An air ambulance helicopter
                                                     flying to pick up a patient
                                                     experienced a partial power
                                                     loss, followed by a hard
                                                     landing in a parking lot.
    2004        135  Night    2 injuries,   OK    An air ambulance helicopter
                                                     was substantially damaged
                                 1 uninjured         when it impacted terrain
                                                     following a loss of control
                                                     due to a blanket coming in
                                                     contact with the tail rotor
                                                     blades during flight.
    2004         91  Night    1 fatality,   AZ    An air ambulance helicopter
                                                     was destroyed when it
                                 2 injuries          collided with terrain while
                                                     attempting to land at an
                                                     off-site landing zone.
    2005         91  Day      1 injury,     AZ    An air ambulance helicopter
                                                     readying to land at an
                                 1 uninjured         airport experienced loss of
                                                     control and collided with
                                                     terrain.
    2005         91  Night    1 fatality    MS    An air ambulance helicopter
                                                     was destroyed after
                                                     colliding with trees and the
                                                     ground in adverse weather
                                                     conditions.
    2005         91  Night    2 fatalities, MD    An air ambulance helicopter
                                                     returning to base was
                                 1 injury            destroyed after impacting
                                                     water.
    2005        135  Day      1 fatality,   AR    An air ambulance helicopter
                                                     transporting a patient lost
                                 3 injuries          control and was
                                                     substantially damaged during
                                                     a hard landing.
    2005         91  Day      3 fatalities  CO    An air ambulance helicopter
                                                     was substantially damaged
                                                     when it impacted terrain
                                                     while approaching an
                                                     off-site landing zone.
    2005        135  Day      4 uninjured   IN    An air ambulance helicopter
                                                     was substantially damaged
                                                     following an in-flight loss
                                                     of control after it impacted
                                                     the helipad after takeoff.
    2005         91  Day      3 uninjured   FL    An air ambulance helicopter
                                                     sustained substantial damage
                                                     when it rolled over while
                                                     conducting an emergency
                                                     landing after takeoff.
    2005         91  Night    3 fatalities  WA    An air ambulance helicopter
                                                     was destroyed when it
                                                     impacted ocean waters while
                                                     returning to base.
    2005         91  Night    1 fatality    PA    An air ambulance helicopter
                                                     on a refueling flight was
                                                     destroyed when it impacted
                                                     trees and terrain while
                                                     performing an instrument
                                                     approach to the airport.
    2005        135  Night    1 injury,     WA    An air ambulance helicopter
                                                     during takeoff sustained
                                 3 uninjured         substantial damage after
                                                     impacting an object and
                                                     subsequently impacting
                                                     terrain.
    2005         91  Day      3 uninjured   MN    An air ambulance helicopter
                                                     sustained substantial damage
                                                     during an aborted takeoff
                                                     after a loss of power.

    Source: GAO analysis of NTSB data.

    Appendix III: Comments from the Association of Air Medical Services

    Appendix IV: GAO Contact and Staff Acknowledgments

    GAO Contact

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

    Staff Acknowledgments

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

    (540123)

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    Highlights of [43]GAO-07-353 , a report to the Chairman, Subcommittee on
    Aviation, Committee on Transportation and Infrastructure, House of
    Representatives

    February 2007

    AVIATION SAFETY

    Improved Data Collection Needed for Effective Oversight of Air Ambulance
    Industry

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

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

    [44]What GAO Recommends

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

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

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

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

    Air Ambulance Helicopter

    References

    Visible links
      30. http://www.gao.gov/cgi-bin/getrpt?GAO-05-728
      31. http://www.gao.gov/cgi-bin/getrpt?GAO-06-266T
      32. http://www.faa.gov/library/manuals/examiners_inspectors/8000/media/N8000-333.pdf
      33. http://www.gao.gov/cgi-bin/getrpt?GAO-05-726
      43. http://www.gao.gov/cgi-bin/getrpt?GAO-07-353
    *** End of document. ***