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			 

******************************************************************
** This file contains an ASCII representation of the text of a  **
** GAO Product.                                                 **
**                                                              **
** No attempt has been made to display graphic images, although **
** figure captions are reproduced.  Tables are included, but    **
** may not resemble those in the printed version.               **
**                                                              **
** Please see the PDF (Portable Document Format) file, when     **
** available, for a complete electronic file of the printed     **
** document's contents.                                         **
**                                                              **
******************************************************************
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 Industryï¿½s
			  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 Industryï¿½s
			  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 [email protected] . 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 [email protected]

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)

GAO's Mission

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

Obtaining Copies of GAO Reports and Testimony

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

Order by Mail or Phone

The first copy of each printed report is free. Additional copies are $2
each. A check or money order should be made out to the Superintendent of
Documents. GAO also accepts VISA and Mastercard. Orders for 100 or more
copies mailed to a single address are discounted 25 percent. Orders should
be sent to:

U.S. Government Accountability Office 441 G Street NW, Room LM Washington,
D.C. 20548

To order by Phone: Voice: (202) 512-6000 TDD: (202) 512-2537 Fax: (202)
512-6061

To Report Fraud, Waste, and Abuse in Federal Programs

Contact:

Web site: www.gao.gov/fraudnet/fraudnet.htm E-mail:
[email protected] Automated answering system: (800) 424-5454 or (202)
512-7470

Congressional Relations

Gloria Jarmon, Managing Director, [email protected] (202) 512-4400 U.S.
Government Accountability Office, 441 G Street NW, Room 7125 Washington,
D.C. 20548

Public Affairs

Paul Anderson, Managing Director, [email protected] (202) 512-4800
U.S. Government Accountability Office, 441 G Street NW, Room 7149
Washington, D.C. 20548

www.gao.gov/cgi-bin/getrpt?GAO-07-353 .

To view the full product, including the scope
and methodology, click on the link above.

For more information, contact Gerald L. Dillingham, Ph.D., at (202)
512-2834 or [email protected].

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. ***