AFS

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## Corrected Copy

This letter corrects the January 29, 2016, letter we sent granting your petition for Exemption No. 10690E

. A c orrection was made to re flect a change to page 9 (last paragraph) of the FAA’s analysis section to change the Docket No. FAA

- 2015

- 0409 to Docket N o. FAA

2013

- 0034. Below is the amended Exemption No. 10690E that includes the aforementioned change. We have made the correction in our records as of February 4, 2016.

Exemption No. 10690E

UNITED STATES OF AMERICA

DEPARTMENT OF TRANSPORTATION

F EDERAL AVIATION ADMINISTRATION WASHINGTON, DC 20591

In the matter of the petition of

AIRLINES FOR AMERICA

, Regulatory Docket No. FAA

- 2013

- 0034

NATIONAL A IR CARRIER ASSOCIATION

, AND REGIONAL AIRLINE ASSOCIATION

fo r an exemption from §121.803(c) (3) and part 121, Appendix A, paragraph (2) of Title 14, Code of Federal Regulations

GRANT OF EXEMPTION

By letter dated December 29, 2015, Airlines for America (A4A) , the National Air Carrier

Association (NACA) , and the Regional Airline Association (RAA) , on behalf of their passenger airline members and simil arly situated air carriers, petitioned the F ederal A viation

A dministration (FAA) for a limited exemption from Title 14 of the C ode of F ederal

R egulations ( 14 CFR) section 121.803(c)(3) which requires airplanes with seating capacity of more than nine passen gers to carry an Emergency Medical Kit (EMK) with contents as specified in Appendix A to p art 121. Specifically, they requested that FAA issue a long

- term exemption for use during periods of temporary supply shortages, beyond operator control, affecting av ailability of injectable drugs Atropine, Dextrose, Epinephrine and/or Lidocaine, as required in Appendix A to part 121

.

The pertinent requirements from 14 CFR from which A4A, NACA, and RAA seek relief are:

Section 121.803 Emergency medical equipment.2

Se ction 121.803(c) generally requires, for treatment of injuries, medical events, or minor accidents that might occur during flight time, each airplane must have equipment that meets the specifications and requirements of Appendix A of this part. Section 12 1.803(c)(3) specifically requires, in airplanes for which a flight attendant is required, an approved emergency medical kit as modified effective April 12, 2004.

Appendix A to Part 121

— First Aid Kits and Emergency Medical Kits

E MERGENCY M EDICAL K ITS

Appen dix A to part 121 specifically requires, as of April 12, 2004, at least one approved emergency medical kit that must contain certain appropriately maintained medical equipment and drugs in specified quantities, which includes:

• Atropine, 0.5 mg, 5 cc (singl e dose ampule or equivalent) Quantity

- 2

• Dextrose, 50%/50 cc injectable, (single dose ampule or equivalent) Quantity

- 1

• Epinephrine 1:1000, 1 cc, injectable, (single dose ampule or equivalent) Quantity

- 2

• Epinephrine 1:10,000, 2 cc, injectable, (single dose a mpule or equivalent) Quantity

- 2

• Lidocaine, 5 cc, 20 mg/ml, injectable (single dose ampule or equivalent) Quantity

- 2

The petitioners require relief from the following requirements:

Section 121.803(c)(3) prescribes, in pertinent part, that airplanes with seating capacity of more than nine passengers carry an Emergency Medical Kit (EMK) with contents as specified in Appendix A to p art 121, which includes Atropine, Dextrose, Epinephrine and Lidocaine

.

The petitioners support their request with the followi ng information:

The petitioners noted that

, since 1986, large passenger

- carrying aircraft have been required to carry an EMK to assist crewmembers or other volunteers in responding to an in

- flight medical emergency. The scope of that requirement was expan ded in 1995 to cover 20

- 30 seat commuter aircraft (60 FR 65831). In 2001, the FAA issued new regulations implementing the Aviation Medical Assistance Act of 1998 which, among other provisions, called for airlines to augment their EMKs and include Atropine, Dextrose, Epinephrine and Lidocaine (66 FR 19028).

The petitioners additionally noted that the regulatory provisions enhancing the required contents of the EMK took effect April 12, 2004, and apply to all airplanes for which a flight attendant is require d, which currently includes all passenger

- carrying aircraft having a seating capacity of more than nine passengers. The petitioners added that the EMK is considered a

“no

- go” item that must be on board for the airplane to be operated, and current Master

Mi nimum Equipment List (MMEL) relief requires a carrier to repair or replace an EMK within one flight of an incomplete, missing or inoperative EMK. They further noted that there3

is no MEL relief permitting a carrier to depart with an EMK missing any specifie d contents beyond the one flight relief previously described.

The petitioners added that shortages occur due to multiple factors, including overall non

aviation demand and manufacturing shortfalls and relate not simply to shortages of substance

but also to shortages of prescribed aviation packaging (e.g. ampules/pre

- filled syringes or proper dosages). The petitioners additionally noted that suppliers and refurbishers report that they are often unaware of an impending drug shortage until they experience a back

- order notification. The petitioners commented that the Atropine and Dextrose shortages in 2012

- 2014 were good examples of drug shortages that surfaced with little notice. They further

commented that the U

. S

. Food and Drug Administration (FDA) does not require timely manufacturer drug shortage notices and therefore, FDA is not a source for advance

information.

The petitioners commented that suppliers and refurbishers, led by MedAire, Inc. (MedAire) and Banyan International Corporation (Banyan) also re gularly compete with hospitals and other ground

- based users to obtain these drugs. The petitioners further commented that hospitals and first responders actually use the substances rather than discarding them through expiration (as usually occurs in aviati on). Petitioners noted, for example, that Banyan reported that during one shortage, drug manufacturers adopted an Atropine distribution system that placed acute care providers (such as hospitals) ahead of airlines and even with this system,

acute care prov iders were not receiving enough supply, making it even less likely that EMK providers would receive Atropine for use in aviation.

The petitioners additionally noted that thus far, airlines and their EMK suppliers have been able to address temporary short ages through a variety of accommodations and FAA exemptions. They commented that ordinarily, airlines maintain a certain number of extra EMKs to replace those that are opened during a medical event and the opened EMKs are then sent back to the EMK supplier for refurbishment. In addition, all EMKs are restocked periodically since some of the medications they contain have a shelf

- life of as little as one year. Petitioners added, however, that during a shortage, EMKs in which Atropine, Dextrose, Epinephrine or Lidocaine have been used or have expired cannot be refurbished and returned to use, leaving the airline potentially without the means to comply with the requirements of Appendix A to part 121.

The petitioners also noted that while FDA has the authority to extend the expiration date on the drugs, the drug manufacturer must petition the FDA with drug stability data asking for an extension, which no manufacturer has done. Petitioners finally noted that Appendix A to part 121 permits carriers and suppliers t o provide equivalent substances. However, according to MedAire (and confirmed by certain in house air carrier medical staff)

, there is no equivalent substitute for Atropine, for example.

Previous Petitions for Exemption and Subsequent Operator Action4

T he petitioners noted that they requested, and were granted, separate exemptions that

addressed Atropine and Dextrose shortages with short notice to the FAA in early 2013.

Petitioners also noted that

, with subsequent extensions, these exemptions expire on J anuary 31, 2016

, and March 31, 2016

, respectively. The petitioners added that a petition was also submitted in 2010 regarding Epinephrine but was withdrawn as supply recovered.

Petitioners commented that the pattern established by the short

- fused Atropin e and Dextrose petitions, and the withdrawn Epinephrine petition, reflect the uncertainties of information flowing from the drug manufacturers. They further commented that

, for apparently commercial reasons, shortage durations vary widely and are not commu nicated in a timely manner to suppliers and refurbishers of EMKs (principally MedAire and Banyan). They also commented that it is important to note that suppliers of EMKs and the air carriers have unwaveringly demonstrated their responsibility to the publ ic by placing the drugs in EMKs whenever the products have been available, even during periods of exemption.

Petitioners added that the lack of timely predictability of shortages, taken with the highly responsible behavior of kit suppliers , refurbishers, and operators, together underscore the appropriateness of a long

- term exemption that will be used only when supplies are impaired beyond the control of the operators.

Current Shortages

Petitioners noted that

, currently, only the manufacturer Hospira, Inc. ( Hospira ) is reporting a potential disruption of the four injectables in the first quarter of 2016. Specifically, there is a possible recall of pre

- filled syringes impending. This was disclosed to Airlines for America by Banyan on or about December 9, 2015.

Atropine

Petitioners noted that Atropine, a required component of EMKs since 2004, is a “medicine used mainly to increase heart rate that may be needed to assist a passenger with an unstable cardiac rhythm.” They added that Appendix A to part 12 1 specifies that an EMK must include two Atropine 0.5 mg, 5 cc injectable single doses or an Atropine equivalent.

Petitioners additionally noted that major EMK airline suppliers and refurbishers MedAire and Banyan obtain Atropine from four producers in t he United States : Amphastar Pharmaceuticals

Inc. (Amphastar) , Hospira, American Regent/Luitpold (AR/L) , and West

- Ward

Pharmaceuticals (West

- Ward) . Petitioners also noted that

, in its letter that accompanied the first petition addressing Atropine, Banyan po inted out that there are no FDA

- approved foreign Atropine manufacturers authorized to import Atropine into the United States to relieve the shortage.

Dextrose5

Petitioners also noted that Dextrose, a required component of EMKs since 1986, is a

“medicine used to treat acute or severe hypoglycemia which may appear in diabetic passengers.” They added that Appendix A to part 121 specifies that an EMK must include one Dextrose 50%/50 cc injectable single dose or a Dextrose equivalent.

Petitioners additiona lly noted that major EMK airline suppliers and refurbishers MedAire and Banyan obtain Dextrose from two producers in the United States : Amphastar and Hospira. They added that Appendix A to part 121 permits carriers and suppliers to provide a Dextrose equi valent

, and MedAire states two Dextrose 25% doses (equivalent to one 50% dose) or one 1mg Glucagon dose (providing similar therapeutic effects) would be equally effective alternatives, but the future availability of these alternative drugs is also unpredic table.

Epinephrine

Petitioners also noted that Epinephrine, a required component of EMKs since 2004, is a “medication used mainly for cardiac resuscitation.” They added that Appendix A to part 121 specifies that an EMK must include two 1:1000, 1cc sing le dose ampules and two 1:10,000, 2cc single dose ampules of Epinephrine or respective equivalents.

Petitioners additionally noted that major EMK airline suppliers and refurbishers MedAire and Banyan obtain Epinephrine from four producers in the United S tates : Amphastar, Hospira, AR/L, and Par Pharmaceuticals (Par)

.

Lidocaine

Lastly, petitioners noted that Lidocaine, a required component of EMKs since 2004, is a “medication used mainly in cases of unresponsiveness to defibrillation and possibly for

ma intenance of normal heart rhythm after successful defibrillation

. ” They added that Appendix A to part 121 specifies that an EMK must include two 5 cc, 20 mg/ml, injectable (single dose ampule or equivalent) of Lidocaine.

Petitioners additionally noted th at major EMK airline suppliers and refurbishers MedAire and Banyan obtain Lidocaine from four producers in the United States : Amphastar, Hospira,

Aurobinda Pharma (Aurobinda) , and Fresenius Kabi USA, LLC (Fresenius Kabi)

.

The Applicable Regulations and R elief Sought

The petitioners indicated that they seek a long

- term exemption from § 121.803(c)(3), which requires passenger

- carrying airplanes to be equipped with an EMK containing Atropine, Dextrose, Epinephrine and Lidocaine as specified in Appendix A t o part 121

, First Aid Kits and Emergency Medical Kits , during periods of supply disruptions beyond the control of the EMK suppliers and the air carriers, which may be on a EMK

- by

- EMK basis, with appropriate labeling of the EMK indicating the missing conten ts.

Reasons for seeking the relief include:6

The petitioners noted that: 1) Suppliers cannot provide EMKs stocked with the drugs when pharmaceutical manufacturers do not deliver product and have not supplied revised fulfillment dates. 2) Replacement su pplies of these substances cannot be imported from foreign manufacturers. 3) There is no accepted substitute for Atropine, and where substitutes for other drugs may exist, their supplies are no more dependable. 4) These drugs are rarely used

.

• Banyan est imates that Atropine is used less than one time per one thousand units

serviced

• Dextrose is rarely used

, having been recommended during approximately .02% in

flight consultations provided by MedAire in 2012. Banyan estimates that Dextrose has

been used in fewer than 0.4% of inflight emergencies reported to Banyan in 15 years.

• Epinephrine is also rarely used, having been administered in 0.3% of inflight medical emergencies

, per a 2013 study by the New England Journal of Medicine (NEJM). ( “Outcomes of Medic al Emergencies on Commercial Airline Flights”, Peterson, Drew C. M.D., et. al., The New England Journal of Medicine, May 30, 2013)

• Lidocaine is even more rarely used, aggregated within “other” by the same NEJM study. 5) When member air carriers contact t he petitioners indicating their supply of EMKs with unexpired Atropine, Dextrose, Epinephrine or Lidocaine will be depleted soon, the problem is often merely weeks away with potential service disruption looming.

The petitioners stated that

, without the r equested relief, air carriers will periodically and

, with little notice, face the decision to ground aircraft. The petitioners requested long

- term relief from the requirement to carry Atropine, Dextrose, Epinephrine or Lidocaine in an EMK due to shortages of those drugs resulting from uncontrollable supply deficit.

Granting the Exemption Would be in the Public Interest

The petitioners noted that

, absent this relief, there are no means for airlines to comply with § 121.803, Appendix A to part 121 , and M EL requirements when shortages exist and the drugs need to be restocked in the EMK. They further noted that this creates the possibility that aircraft would have to be taken out of service until additional supplies can be obtained

, and

that

, while this wou ld be a last resort, it is not implausible. The petitioners added that grounding otherwise airworthy aircraft for this reason alone would disrupt air service and would not be in the interest of the traveling public. They added that granting this exemption would help to ensure that air service continues uninterrupted and

, in this respect

, would serve the public interest.

Granting the Exemption Would Not Adversely Affect Safety

The petitioners commented that shortages of these drugs to date have additiona lly brought to light their limited usage. They added that

, for example, MedAire has reported that roughly 1%7

of EMKs returned for refurbishment are missing Atropine due to use, loss, or damage. The petitioners further added that a returned EMK, unless open ed for use, represents approximately one year of service and is generally returned for replacement of expiring contents. The petitioners added that MedAire and Banyan have both reported to the petitioners qualitatively that the majority of drug usage for a irline purposes has been due to expiration, not administration to passengers. Petitioners also noted that

, for example, Banyan reports that Atropine is used less than one time per one thousand units serviced

, and as previously referenced, usage of the othe r injectables is also rare.

The petitioners reiterated that suppliers and refurbishers of EMKs and the air carriers have unwaveringly demonstrated their responsibility to the public by placing the required drugs in EMKs, even during periods of exemption, whenever the products have been available.

The petitioners generally noted that EMKs are not intended to be comprehensive, or to include treatment for every possible medical condition but instead provide options for addressing the most frequent types of in

- flight medical emergencies. They added that the

case

- by

- case removal of the EMK requirement for these drugs during acute shortages would not adversely affect the safety of the traveling public because they are used so infrequently.

Reasons for Exerci sing the Privileges of the Requested Exemption Outside the United

States

The petitioners also noted that

, due to the unpredictable nature of situations in which this exemption might be used, and in order to avoid disruptions in international operations, U.S. carriers would need to be able to exercise the privileges of this exemption outside the United States. They added that the International Civil Aviation Organization (ICAO) standard requires aircraft to be equipped with “accessible and adequate medical supplies” and recommends that these supplies include, for aircraft authorized to carry more than 100 passengers on a flight of more than two hours, “a medical kit, for the use of medical doctors or other qualified persons in treating in

- flight medical eme rgencies.” The petitioners further added that additional guidance provided by ICAO recommends, but does not require, Atropine, Dextrose, and Epinephrine. The petitioners noted, therefore, that the absence of Atropine, Dextrose, and Epinephrine in an EMK on an aircraft operating outside the United

States would not violate ICAO requirements.

The FAA has determined that good cause exists to waive publication of a summary of this petition for exemption in the Federal Register for public comment. Delaying actio n on this petition would adversely affect air carriers due to the imminent effect on operations that would be caused by the possible shortages of Atropine, Dextrose, Epinephrine or Lidocaine

.

The FAA’s analysis is as follows:

The FAA has considered fully the petitioners’ request and supporting information and finds that a grant of exemption would be in the public interest.8

First, the FAA notes that there are two current exemptions related to this petition for exemption. Exemption No. 10690 (FAA

- 2013

- 00 34) granted passenger member airlines of the Regional Airline Association, Airlines for America, and National Air Carrier Association, and all similarly situated air carriers, an exemption from § 121.803(c)(3) and Appendix A to part 121, to the extent nec essary to relieve them from the requirement to carry two single dose ampules of Atropine 5cc injectable, in required on

- board EMKs when, due to the nationwide shortage, they are unable to procure these items for the kits. The current extension of Exemption No. 10690 (10690D) terminates on January 31, 2016.

Exemption No. 10721 ( FAA

- 2013

- 0201) granted passenger member airlines of Regional Airline Association, Airlines for America, and National Air Carrier Association, and all similarly situated air carriers, an exemption from § 121.803(c)(3) and Appendix A to part 121 to the extent necessary to relieve them from the requirement to carry one single dose ampule of Dextrose 50cc injectable , in required on

- board EMKs when, due to the nationwide shortage, they are unable to procure these items for the kits. The current extension of Exemption No. 10721 (10721A) terminates on March 16, 2016.

Second, the FAA notes that the conditions and reasons relative to public interest and safety that were the basis for granting Exemption No. 10690

, regarding the shortage of Atropine

, and Exemption No. 10721

, regarding the shortage of Dextrose

, are also valid with respect to possible future shortages of Epinephrine and Lidocaine for suppliers and refurbishers of

EMKs used in air c arrier operations under part 121.

All airplanes for which a flight attendant is required must carry an EMK with items listed in Appendix A to part 121 . The EMK is considered a “no

- go” item and is included on the

MMEL . Current MMEL Policy Letter 73, titled “MMEL Relief for Emergency Medical Equipment,” requires an air carrier to repair or replace an EMK within one flight when it is incomplete, missing, or inoperative. There is no MMEL relief permitting an air carrier to depart with an EMK that is missing re quired EMK contents beyond the one flight relief described in MMEL Policy Letter 73

.

The inability of EMK suppliers and refurbishers to obtain and supply Atropine, Dextrose, Epinephrine and/or Lidocaine during shortages of one or more of these drugs crea tes the possibility that a significant number of aircraft would not be able to meet the requirements of Appendix A to part 121 and would have to be taken out of service. As discussed in the petition for exemption, safety would not be adversely affected bec ause data from EMK suppliers and refurbishers demonstrate that Atropine, Dextrose, Epinephrine and/or Lidocaine are rarely used and predominantly replaced in EMKs due to expiration. Therefore, the case

by

- case removal of the EMK requirement for these drugs during acute shortages would not adversely affect the safety of the traveling public because they are used so infrequently.

Additionally, the FAA has determined that the impact on large numbers of passengers that would be caused by grounding these aircra ft for lack of Atropine, Dextrose, Epinephrine and/or Lidocaine outweighs the benefit of having them

, since they are used infrequently in response to in

- flight medical events.9

As the petitioners indicate, shortages occur due to multiple factors, includin g overall non

aviation demand and manufacturing shortfalls, and relates not simply to shortages of substance but also to shortages of prescribed aviation packaging (ampules/pre

- filled syringes or proper dosages). The FAA also agrees with the petitioners th at the Atropine and Dextrose shortages that occurred during 2012

- 2014 were appropriate examples of drug shortages that

surfaced with little notice.

Further, the FAA agrees with the petitioners that it is important to note that suppliers of

EMKs and air ca rriers have consistently demonstrated their responsibility to the public by placing the drugs in EMKs whenever the products have been available, even during periods of exemption.

In considering this petition for exemption, the FAA recognizes that air carr iers must cope with periodic nationwide manufacturing shortages for certain drugs that leave affected certificate holders without an alternate means to comply. Further, the nationwide shortages affect not only EMK suppliers for aviation use, but also groun d

- based medical service providers such as hospitals and first responders that provide acute medical care on a frequent basis.

The FAA notes that the great majority of passenger

- carrying air carriers operating under part 121 use EMKs that are supplied and /or refurbished by only three companies; MedAire, Inc., Banyan International Corporation and Aerospace Accessory Service, Inc.. Additionally, all EMK suppliers and/or refurbishers must obtain these drugs from four or fewer drug manufacturers. Therefore, r egardless of air carrier size, fleet type(s), operating environment or business model, all air carriers operating under part 121 are similarly situated regarding the ability to obtain Atropine, Dextrose, Lidocaine and/or Epinephrine for EMKs used on their

aircraft.

Previously, when Airlines for America, Regional Airline Association and National Air Carrier Association petitioned the FAA for relief from certain requirements regarding EMK contents, the FAA granted relief to member airlines of these petitione rs, as well as to all other “similarly situated” air carriers, which included any air carrier operating under the provisions of part 121 (Exemption No s . 10690D and 10721A). However, in an effort to manage the exemptions granted by the FAA and to facilitat e operator compliance with the conditions and limitations of a grant of exemption, the FAA is no longer including “similarly situated air

carriers” in the grants of exemption

.

In order for any air carrier that is not a member or associate member of Airli nes for America, Regional Airline Association or National Air Carrier Association (petitioners) to exercise the relief provided by this grant of exemption, they must submit a petition for similar relief to

Docket FAA

- 201 3

- 0 034 that references Exemption No. 10690E. After analysis of the petition, if appropriate, the FAA will amend Exemption No. 10690E to include the additional

air carrier. An a ir carrier may only exercise the relief provided by this grant of exemption

when it is listed in Attachment 1 to Exe mption No. 10690E , as amended.10

The FAA’s Decision :

In consideration of the foregoing, I find that a grant of exemption is in the public interest. Therefore, pursuant to the authority contained in 49 U.S.C. §§ 106(f), 40113, and 44701, delegated to me b y the Administrator, I grant the current members and associate members of Airlines for America, the National Air Carrier Association, and the Regional Airline Association, an exemption from 14 CFR § 121.803(c)(3) to the extent necessary to allow

aircraft t o be operated without meeting the requirements of Appendix A to part 121 regarding emergency medical kit (EMK) required contents Atropine, Dextrose, Epinephrine and/or Lidocaine, when EMK suppliers and /or refurbishers are unable to obtain and supply Atropi ne, Dextrose, Epinephrine and/or Lidocaine.

As previously noted, this grant is limited to the members and associate members, as of the date of this Grant of Exemption, of Airlines for America, the National Air Carrier Association, and the Regional Airline Association

, as listed in Attachment 1 of this Grant of Exemption. Any new or additional members of these associations or other air carriers operating under the provisions of part 121 must petition the FAA separately to be able to

exercise similar relief as that provided by this grant of exemption. Air carriers may only exercise the relief provided by this grant of exemption when they are listed in Attachment 1 to Exemption No. 10690E

, as amended.

This exemption is subject to the following conditions and limitations:

Conditions and Limitations

1. A copy of this exemption must be carried on board each aircraft operating with an emergency medical kit (EMK) that do es not include Atropine, Dextrose, Epinephrine

and/or Lidocaine as required by Appendix A to p art 121.

2. As part of the requirement under §119.43(c) to keep each of its employees and other persons used in its operation informed of the provisions of its operations specifications that apply to that employee’s or person’s duties and responsibilities, the certificate holders must inform crewmembers that an emergency medical kit on board that aircraft may not contain Atropine, Dextrose, Epinephrine and/or Lidocaine

.

3. Should the supply of Atropine, Dextrose, Epinephrine and/or Lidocaine become

available to EMK suppliers and/or refurbishers, exemption holders must refurbish the

EMK with the missing drug(s) at the next scheduled refurbishment date.

4. This exemption may be used for flights conducted outside of the United States.11

This exemption terminates o n January 31, 2020, unless sooner superseded or rescinded.

Issued in Washington, DC, on January 29, 2016.

/s/

John S. Duncan Director, Flight Standards Service12

Attachment 1

The relief provided by Exemption No. 10690E is limited to the air carrier s listed below:

Airlines for America

Alaska Airlines

American Airlines Atlas Air, Inc. Hawaiian Airlines, Inc. JetBlue Airways Corp.

Southwest Airlines Co. United Airlines, Inc Air Canada (Associate Member)

National Air Carrier Association Air Transpor t International Allegiant Air Atlas Air, Inc.

Eastern Airlines Everts Air Cargo

Kalitta Air Lyndon Air Cargo

Miami Air International

National Airlines National Air Cargo Northern Air Cargo

Omni Air International

Southern Air Spirit Airlines Sun Country Air lines

USA Jet Airlines

Western Global

Regional Airline Association Air Wisconsin Airlines Corp. Cape Air

CommutAir Compass Airlines Empire Air

Endeavor Airlines Envoy ExpressJet Airlines

GoJet Airlines Grand Canyon Airlines/Scenic

Great Lakes Aviation13

Haw aii Island Air

Horizon Air

Jazz Air

Mesa Airlines New England Airlines

Piedmont Airlines PSA Airways

RAVN Alaska Republic Airlines

Seaborne Airlines

Shuttle America Silver Airways SkyWest Airlines

Surf Air

Trans States Airlines

Additional Air Carriers