United States Government Accountability Office

GAO Report to the Chairman, Subcommittee 

on Aviation, Committee on 

Transportation and Infrastructure, 

House of Representatives 

AVIATION SAFETY

Improved Data 

Collection Needed for 

Effective Oversight of 

Air Ambulance 

Industry 

February 2007 

 

GAO-07-353 
What GAO Found

United States Government Accountability Office

Why GAO Did This Study

Highlights

Accountability Integrity Reliability

February 2007

AVIATION SAFETY

Improved Data Collection Needed for 

Effective Oversight of Air Ambulance 

Industry 

Highlights of GAO-07-353, a report to the 

Chairman, Subcommittee on Aviation, 

Committee on Transportation and

Infrastructure, House of Representatives 

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. 

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 

Source: Clare McLean © 2006.

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 

dillinghamg@gao.gov. 
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 

Page i GAO-07-353 Air Ambulance Safety
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. 

Page ii GAO-07-353 Air Ambulance Safety
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 

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. 

Page 1 GAO-07-353 Air Ambulance Safety e Safety
Figure 1: Air Ambulance Helicopter 

Source: Clare McLean © 2006.

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 

Page 2 GAO-07-353 Air Ambulance Safety
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. 

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 

Results in Brief 

Page 3 GAO-07-353 Air Ambulance Safety
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.

Page 4 GAO-07-353 Air Ambulance Safety
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. 

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 

Background 

Air Ambulance Operations 

Perform Various Duties 

and Take Several Forms 

Page 5 GAO-07-353 Air Ambulance Safety
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. 

 1

Such 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. 

2

For the purposes of this report, the use of the term “operator” refers to the FAA certificate 

holder.

Page 6 GAO-07-353 Air Ambulance Safety
Figure 2: Helicopter Air Ambulance Service Locations

Sources: Atlas and Database of Air Medical Services (ADAMS); compiled by CUBRC’s Center for Transportation Injury Research 

(CenTIR) in alliance with the Association of Air Medical Services (AAMS) with support from the Federal Highway Administration 

(FHWA) and National Highway Traffic Safety Administration (NHTSA); composite map by GAO. 

 Helicopter air ambulance base locations

Page 7 GAO-07-353 Air Ambulance Safety
Air ambulance operations can take many different forms but are generally

one of two types—hospital-based or stand-alone:3

• 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

• 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. 

 3

Other 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. 

4

A 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. 

Page 8 GAO-07-353 Air Ambulance Safety
Table 1: Examples of Independent and Hospital-Based Operators 

Characteristic Independent operator Hospital-based operator

Program Petroleum Helicopters

International Air Medical 

Teddy Bear Transport 

Cook Children’s Medical 

Center 

Holder and location of 

FAA operating 

certificate 

Petroleum Helicopters 

International (PHI); 

Lafayette, Louisiana 

CJ Systems; 

Harrisburg, Pennsylvania 

Number of bases 49 1 

Location of bases 14 states Fort Worth, Texas

Number of helicopters 224 1 

Tax status For profit Nonprofit 

Flight crew employer PHI CJ Systems 

Medical crew 

employer 

PHI Cook Children’s Medical 

Center 

Revenue sources Per-flight basis Patient flights, hospital 

admission 

Mission profile 50% on-scene

50% hospital-to-hospital 

100% hospital-to-hospital 

Source: GAO.

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. 

Government and Industry 

Both Play a Role in Air 

Ambulance Oversight 

Page 9 GAO-07-353 Air Ambulance Safety
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

 5

Operating Requirements: Commuter and On Demand Operations and Rules Governing

Persons on Board Such Aircraft, 14 C.F.R. pt. 135 (2006). 

6

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

7

According 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. 

Page 10 GAO-07-353 Air Ambulance Safety
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 

Reposition

(Part 91)

En route

(Part 91)

Transport

(Part 135)

Source: GAO.

Page 11 GAO-07-353 Air Ambulance Safety
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 industrydriven 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

 8

National Transportation Safety Board, Special Investigative Report on Emergency

Medical Services Operations (Washington, D.C., 2006). 

9

National Transportation Safety Board, Safety Study: Commercial Emergency Medical 

Services Helicopter Operations (Washington, D.C., 1988). 

Page 12 GAO-07-353 Air Ambulance Safety
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. 

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. 

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

Increase in Size and 

Safety-Related 

Concerns Mark 

Industry’s Recent 

Years

Data Limitations Preclude 

Complete Understanding 

of Industry’s Growth 

 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.

Page 13 GAO-07-353 Air Ambulance Safety
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. 

 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. 

Page 14 GAO-07-353 Air Ambulance Safety
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

0

100

200

300

400

500

600

700

800

2003 2004 2005

Number

Source: Association of Air Medical Services, Atlas and Database of Air Medical Services.

Year

Bases

Aircraft

 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. 

Page 15 GAO-07-353 Air Ambulance Safety
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. 

 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). 

Page 16 GAO-07-353 Air Ambulance Safety
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. 

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). 

Growth Is Primarily in 

Stand-Alone Businesses 

and Has Led to Increased 

Competition in Some 

Locales 

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

Page 17 GAO-07-353 Air Ambulance Safety
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 

0

100

200

300

400

500

600

700

2003 2004 2005

Number

Year

Airport and helipad

Hospital-based

Source: Association of Air Medical Services, Atlas and Database of Air Medical Services.

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

Page 18 GAO-07-353 Air Ambulance Safety
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: 

• 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. 

 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. 

Page 19 GAO-07-353 Air Ambulance Safety
• 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. 

• 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. 

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). 

Increase in Number of 

Accidents Has Led to 

Greater Industry Focus on 

Safety-Related Activities 

 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.

Page 20 GAO-07-353 Air Ambulance Safety
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 

0

2

4

6

8

10

12

14

16

18

20

1998 1999 2000 2001 2002 2003 2004 2005

Total accidents

Source: GAO analysis of NTSB data.

Year

Page 21 GAO-07-353 Air Ambulance 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 management23 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. 

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 Advisory Council

(AMSAC) 

Develops recommended practices for the industry. 

2001/2002 AMSAC Implemented “Train the Trainer” Air Medical Resource Management 

programs. 

2002 Air Medical Physicians Association Published “A Safety Review and Risk 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 Nurses 

Association 

Published a position paper on transport 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. 

Page 22 GAO-07-353 Air Ambulance Safety
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. 

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. 

FAA Safety Oversight 

Does Not Fully 

Address Industry’s 

Operational Risks 

Air Ambulance Operations 

Face Risks Different from 

Those Faced by Other 

Operations Subject to Part 

135 Regulations 

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. 

Page 23 GAO-07-353 Air Ambulance Safety
• 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 offairport/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: 

• 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). 

 25Our analysis of NTSB data from 1998 through 2005 included 89 air ambulance helicopter

accidents and 1,129 non-air-ambulance helicopter accidents. 

Page 24 GAO-07-353 Air Ambulance Safety
Figure 7: Time of Day of Air Ambulance Fatal and Nonfatal Accidents, 1998 to 2005 

0

20

40

60

80

100

Night Day

Percentage

Source: GAO analysis of NTSB data.

Accident time of day

Fatal

Nonfatal

• 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. 

Page 25 GAO-07-353 Air Ambulance Safety
Figure 8: Percentage of Air Ambulance and Other Helicopter Accidents Associated

with Adverse Weather, 1998 to 2005 

0

5

10

15

20

Accidents associated with adverse weather

Percentage

Source: GAO analysis of NTSB data.

Air Ambulance

Non-Air-Ambulance

• 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. 

• 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 

Page 26 GAO-07-353 Air Ambulance Safety
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. 

• 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. 

• 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: 

• 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. 

Page 27 GAO-07-353 Air Ambulance Safety
• 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 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 

FAA Inspections 

Framework Is Not Tailored 

to Risks of the Air 

Ambulance Industry 

 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). 

Page 28 GAO-07-353 Air Ambulance Safety
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. 

• 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. 

• 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 

 28GAO, Aviation Safety: FAA Management Practices for Technical Training Mostly

Effective; Further Actions Could Enhance Results, GAO-05-728 (Washington, D.C.: Sept. 7,

2005). 

Page 29 GAO-07-353 Air Ambulance Safety
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. 

• 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 

 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. 

Page 30 GAO-07-353 Air Ambulance Safety
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

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, 

Part 135 Regulations Do 

Not Address Specific 

Dangers Inherent in Air 

Ambulance Transports 

 30GAO, Aviation Safety: FAA’s Safety Oversight System Is Effective but Could Benefit

from Better Evaluation of Its Programs’ Performance, 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. 

Page 31 GAO-07-353 Air Ambulance Safety
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 twoway 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 

 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. 

Page 32 GAO-07-353 Air Ambulance Safety
organizations consider flights that utilize instruments to be much safer 

than the flights that rely solely on visual cues. 

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 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 

FAA Efforts to 

Improve Safety Are 

Under Way, but 

Effects Are Not Being 

Measured 

FAA Efforts Targeted at 

Improving Air Ambulance 

Safety Oversight Include 

Issuing Guidance, 

Expanding Inspection 

Resources, and 

Collaborating with the 

Industry 

FAA Guidance Focuses on 

Identified Safety Concerns 

Page 33 GAO-07-353 Air Ambulance Safety
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. 

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

Date Type of action Title Purpose

January 2005 Notice 8000.293 (on Jan. 28, 

2006, became permanent 

through Safety Alert for 

Operators 06001) 

Helicopter Emergency Medical 

Service Operations 

Provides guidance for FAA safety inspectors to 

help operators review pilot and mechanic 

decision-making skills, procedural adherence,

and crew resource management practices. 

August 2005 Notice 8000.301 Operational Risk Assessment

Programs for Helicopter 

Emergency Medical Services 

Provides guidance to FAA inspectors to promote 

improved risk assessment programs and risk 

management tools and training to all flight 

crews, including medical staff. 

September 2005 Notice 8000.307 Special Emphasis Inspection

Program for Helicopter 

Emergency Medical Services 

Provides guidance to FAA safety inspectors of 

air ambulance operators to place 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 2005 Advisory Circular 00-64 Air Medical Resource 

Management 

Provides guidance to operators to establish 

minimum training guidelines for all air medical 

team members. 

January 2006 Flight Standards Handbook 

Bulletin for Air Transportation, 

06-02

Helicopter Emergency Medical 

Services Loss of Control and 

Controlled Flight into Terrain 

Accident Avoidance Programs

Provides information to inspectors about pilot 

training and checking standards and requires a 

review of air ambulance operator training 

programs. 

January 2006 Flight Standards Handbook

Bulletin for Air Transportation,

06-01

Helicopter Emergency Medical 

Services; OpSpec A021/A002 

Revisions 

Provides guidance to principal operations 

inspectors about revisions to the weather 

minimums for air ambulance operators. 

March 2006 Notice 8000.318 Public Helicopter Emergency 

Medical Services Operations 

Provides guidance to inspectors to ensure that 

public air 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 Information 

Manual 

Helicopter Night Visual Flight

Rule Operations

Provides information and guidance concerning 

night celestial and man-made lighting on seeing 

conditions in night visual flight rule operations. 

August 2006 Aeronautical Information 

Manual 

Landing Zone Information Provides information and guidance on the 

selection of ad-hoc helicopter landing sites by

ground responders and the use of such sites by 

helicopter operators. 

Page 34 GAO-07-353 Air Ambulance Safety
Date Type of action Title Purpose

November 2006 Notice 8000.333 Helicopter Emergency Medical 

Services (HEMS) use of the 

Aviation Digital Data Service 

(ADDS) Experimental HEMS 

Tool

Provides information and guidance to principal 

inspectors on the use of the ceiling and visibility 

tool developed as a result of the 2006 Weather 

Summit. 

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 

Page 35 GAO-07-353 Air Ambulance Safety
effective than generating new regulations and has encouraged air 

ambulance operators to adopt FAA guidance to the maximum extent 

possible to enhance safety. 

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. 

Additional FAA Resources 

Allocated to Air Ambulance 

Oversight 

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 

 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, 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. 

Page 36 GAO-07-353 Air Ambulance Safety
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.

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 Has Increased 

Collaboration with the Industry 

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. 

Page 37 GAO-07-353 Air Ambulance Safety
Table 4: NTSB Recommendations and FAA Responses 

NTSB recommendation to FAA FAA response 

Require all air ambulance operators to comply with Part 

135 operations specifications during the conduct of all 

flights with medical personnel on board. 

FAA is looking at options to address concerns about the differences in 

the flight rules—specifically the weather minimums—through new 

weather reporting requirements and the application of “eligible on 

demand” standards to air ambulance helicopter operations. 

Require all air ambulance operators to develop and 

implement flight risk evaluation programs. 

FAA has implemented this recommendation with the publication of 

Notice 8000.301. 

Require air ambulance operators to use formalized

dispatch and flight-following procedures. 

FAA has a study under way to identify best industry practices in 

ground communication and dispatch to support effective FAA 

requirements and policy. 

Require air ambulance operators to install terrain 

awareness and warning systems on their aircraft and to 

provide adequate training to ensure that flight crews are 

capable of using the systems. 

FAA has emphasized the strategic avoidance of controlled flight into 

terrain accidents in Flight Standards Handbook Bulletin for Air 

Transportation, 06-02. At FAA request, RTCA Inc., a private 

corporation, has formed a special 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. 

Page 38 GAO-07-353 Air Ambulance Safety
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

FAA Lacks an Approach 

for Evaluating the Effects 

of Its Efforts 

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). 

Page 39 GAO-07-353 Air Ambulance Safety
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. 

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. 

Conclusions 

Page 40 GAO-07-353 Air Ambulance Safety
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: 

• 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. 

• Collect information on the implementation of voluntary FAA guidance by 

air ambulance operators and evaluate the effectiveness of that guidance.

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. 

Recommendations for 

Executive Action 

Agency Comments 

and Our Evaluation 

Page 41 GAO-07-353 Air Ambulance Safety
If you have any questions about this report, please contact me at (202) 512-

2834 or dillinghamg@gao.gov. Contact points for our Offices of 

Congressional Relations and Public Affairs may be found on the last page 

of this report. GAO staff who made major contributions to this report are 

listed in appendix IV. 

Sincerely yours, 

Gerald L. Dillingham, Ph.D. 

Director, Physical Infrastructure Issues 

Page 42 GAO-07-353 Air Ambulance Safety
Appendix I: Scope and Methodology 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 

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 

Source: GAO.

Page 43 GAO-07-353 Air Ambulance Safety
Appendix I: Scope and Methodology 

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

 1

There is no clear consensus about what constitutes an air ambulance accident; thus, other 

studies may present different accident totals covering the same time period. 

Page 44 GAO-07-353 Air Ambulance Safety
Appendix I: Scope and Methodology 

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. 

 2

Large 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. 

Page 45 GAO-07-353 Air Ambulance Safety
Appendix I: Scope and Methodology 

Table 6: Description of States Selected for Site Visits 

State Description of air ambulance market Description of programs visited

Arizona Providers: 10

Helicopters: 50

Accidents, 1998 to 2005: 8

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. 

• Native Air, a subsidiary of Omniflight Helicopters, is a 

community-based operator, and its fleet is composed of 15 

helicopters located at 12 bases in Arizona and Montana. 

California Providers: 28

Helicopters: 72

Accidents, 1998 to 2005: 7 

State requirements: The state of California has 

delegated authority to local governments for emergency 

medical services (EMS). County governments are 

responsible for coordinating emergency medical 

services, including the coordination and monitoring of 

air ambulance services. 

• The FlightCare Program at Enloe Medical Center is a 

nonprofit hospital-based program. The program’s fleet 

consists of one helicopter based at the Enloe Hospital 

helipad. 

• REACH is an independent for-profit air ambulance 

provider. The company has seven helicopters and nine 

bases in California and Oregon. 

• CALSTAR is a nonprofit community-based program. The 

company’s fleet consists of 11 helicopters and seven bases 

in California. 

• 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

Helicopters: 18

Accidents, 1998 to 2005: 1

State requirements: Maryland requires private providers 

of air ambulance services operating in the state to be 

licensed by the state and CAMTS accredited. 

• The Maryland State Police Aviation Command is a 

public provider and has a fleet of 12 helicopters based in

eight locations across the state. 

Texas Providers: 23

Helicopters: 61

Accidents, 1998 to 2005: 13

State requirements: The state requires air ambulances 

and providers to be licensed by the Texas Department 

of State Health Services. The licensure process 

requires providers to submit a copy of their current FAA 

operational certification that includes designation for air 

ambulance operations. 

• Teddy Bear Transport of Cook Children’s Medical 

Center is a hospital-based program that conducts hospitalto-hospital transports for pediatric patients. The program 

contracts with a vendor for its aviation services and 

operates one helicopter. 

• PHI Air Medical is an independent program conducting a 

mix of scene response and hospital-to-hospital transports. 

PHI’s programs in Texas include 12 helicopters stationed at

12 bases. In total, the company has 224 air ambulance 

helicopters stationed at 49 bases in 14 states. 

Page 46 GAO-07-353 Air Ambulance Safety
Appendix I: Scope and Methodology 

State Description of air ambulance market Description of programs visited

Washington Providers: 2

Helicopters: 10

Accidents, 1998 to 2005: 3

State requirements: The state 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. 

• Airlift Northwest is a nonprofit community-based program. 

The program contracts out its aviation services. Its fleet 

consists of six helicopters stationed at four bases in 

Washington. 

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. 

Page 47 GAO-07-353 Air Ambulance Safety
Appendix II: NTSB Air 

Ambulance Accident Data 

Page 48 GAO-07-353

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 

Year 

Flight 

regulation 

When

accident

occurred 

Number of 

fatalities, 

injuries, or

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. 

Appendix II: NTSB Air Ambulance Accident 

Data 

Air Ambulance Safety
Appendix II: NTSB Air 

Ambulance Accident Data 

Year 

Flight 

regulation 

When

accident

occurred 

Number of 

fatalities, 

injuries, or

uninjured State Accident details

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 offsite 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, 

2 uninjured 

IL An air ambulance helicopter readying for takeoff received

minor damage when a hospital security guard walked into the 

tail rotor. 

Page 49 GAO-07-353 Air Ambulance Safety
Appendix II: NTSB Air 

Ambulance Accident Data 

Year 

Flight 

regulation 

When

accident

occurred 

Number of 

fatalities, 

injuries, or

uninjured State Accident details

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, 

1 injury, 

1 uninjured 

CA An air ambulance helicopter attempting to land at an off-site 

landing zone was destroyed when it encountered brownout 

conditions and collided with trees. 

2001 91 Night 2 injuries, 

1 uninjured 

TX An air ambulance helicopter on a nighttime positioning 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, 

1 injury 

OH An air ambulance helicopter was destroyed when it collided 

with a brick façade during a takeoff from a rooftop helipad in

windy conditions. 

2002 91 Day 1 fatality, 

2 injuries 

CA An air ambulance helicopter en route to pick up a 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. 

Page 50 GAO-07-353 Air Ambulance Safety
Appendix II: NTSB Air 

Ambulance Accident Data 

Year 

Flight 

regulation 

When

accident

occurred 

Number of 

fatalities, 

injuries, or

uninjured State Accident details

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 offsite 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, 

1 injury 

UT An air ambulance helicopter crashed into terrain after 

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, 

2 uninjured 

TX An air ambulance helicopter en route to pick up a 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. 

Page 51 GAO-07-353 Air Ambulance Safety
Appendix II: NTSB Air 

Ambulance Accident Data 

Year 

Flight 

regulation 

When

accident

occurred 

Number of 

fatalities, 

injuries, or

uninjured State Accident details

2003 91 Day 1 fatality, 

1 injury, 

1 uninjured 

UT An air ambulance helicopter en route to its home base after 

completing a patient transport was destroyed when it impacted 

a hillside. 

2003 135 Day 3 injuries, 

1 uninjured 

FL An air ambulance helicopter crashed while attempting to 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 inflight vibration. 

2003 91 Night 1 injury, 

2 uninjured 

TX An air ambulance helicopter sustained substantial damage 

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, 

1 injury 

TX An air ambulance helicopter transporting a patient crashed into 

terrain while maneuvering in reduced visibility. 

2004 135 Night 1 fatality, 

3 injuries 

IN An air ambulance helicopter transporting a patient was 

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.

Page 52 GAO-07-353 Air Ambulance Safety
Appendix II: NTSB Air 

Ambulance Accident Data 

Year 

Flight 

regulation 

When

accident

occurred 

Number of 

fatalities, 

injuries, or

uninjured State Accident details

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, 

1 uninjured 

OK An air ambulance helicopter was substantially damaged 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, 

2 injuries 

AZ An air ambulance helicopter was destroyed when it collided 

with terrain while attempting to land at an off-site landing zone. 

2005 91 Day 1 injury, 

1 uninjured 

AZ An air ambulance helicopter readying to land at an 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, 

1 injury 

MD An air ambulance helicopter returning to base was destroyed

after impacting water. 

2005 135 Day 1 fatality, 

3 injuries 

AR An air ambulance helicopter transporting a patient lost 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. 

Page 53 GAO-07-353 Air Ambulance Safety
Appendix II: NTSB Air 

Ambulance Accident Data 

Year 

Flight 

regulation 

When

accident

occurred 

Number of 

fatalities, 

injuries, or

uninjured State Accident details

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, 

3 uninjured 

WA An air ambulance helicopter during takeoff sustained 

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. 

Page 54 GAO-07-353 Air Ambulance Safety
Appendix III: Comments from the Association of Air Medical Services 

Page 55 GAO-07-353

Appendix III: Comments from the 

Association of Air Medical Services 

Air Ambulance Safety
Appendix III: Comments from the Association of Air Medical Services 

Page 56 GAO-07-353 Air Ambulance Safety
Appendix III: Comments from the Association of Air Medical Services 

Page 57 GAO-07-353 Air Ambulance Safety
Appendix III: Comments from the Association of Air Medical Services 

Page 58 GAO-07-353 Air Ambulance Safety
Appendix III: Comments from the Association of Air Medical Services 

Page 59 GAO-07-353 Air Ambulance Safety
Appendix III: Comments from the Association of Air Medical Services 

Page 60 GAO-07-353 Air Ambulance Safety
Appendix IV: 

A

GAO Contact and Staff 

cknowledgments 

Page 61 GAO-07-353

Appendix IV: GAO Contact and Staff 

Acknowledgments 

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

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. 

Air Ambulance Safety

GAO Contact 

Staff 

Acknowledgments 

(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. 

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.” 

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 

Contact: 

Web site: www.gao.gov/fraudnet/fraudnet.htm

E-mail: fraudnet@gao.gov

Automated answering system: (800) 424-5454 or (202) 512-7470 

Gloria Jarmon, Managing Director, JarmonG@gao.gov (202) 512-4400 

U.S. Government Accountability Office, 441 G Street NW, Room 7125 

Washington, D.C. 20548 

Paul Anderson, Managing Director, AndersonP1@gao.gov (202) 512-4800

U.S. Government Accountability Office, 441 G Street NW, Room 7149 

Washington, D.C. 20548 

Obtaining Copies of 

GAO Reports and 

Testimony

Order by Mail or Phone 

To Report Fraud,

Waste, and Abuse in 

Federal Programs 

Congressional 

Relations 

Public Affairs 

PRINTED ON RECYCLED PAPER