Aviation Safety: Potential Strategies to Address Air Ambulance Safety Concerns
Published: 2009-04-22T00:00:00

Fast Facts:

Highlights:
section_title: Why GAO Did This Study
paragraphs: Air ambulance transport is widely regarded as improving the chances of survival for trauma victims and other critical patients. However, recent increases in the number of air ambulance accidents have led to greater industry scrutiny by government agencies, the public, the media, and the industry itself. The National Transportation Safety Board (NTSB) and others have called on the Federal Aviation Administration (FAA), which provides safety oversight, to issue more stringent safety requirements for the industry. This testimony discusses (1) recent trends in the air ambulance industry with regard to its size, composition, and safety record; (2) recent industry and government efforts to improve air ambulance safety; and (3) potential strategies for improving air ambulance safety. This testimony is based primarily on GAO's February 2007 study on air ambulance safety (GAO-07-353). To update and supplement this 2007 report, GAO analyzed the latest safety information from NTSB and FAA, reviewed published literature on the state of the air ambulance industry, and interviewed FAA officials and industry representatives. GAO provided a copy of the draft testimony statement to FAA. FAA provided technical comments, which GAO incorporated as appropriate.
section_title: What GAO Found
paragraphs: The air ambulance industry has increased in size, and concerns about its safety have grown in recent years. Available data suggest that the industry grew, most notably in the number of stand alone (independent or community-based) as opposed to hospital-based operators, and competition increased among operators, from 2003 through 2008. During this period, the number of air ambulance accidents remained at historical levels, fluctuating between 11 and 15 accidents per year, and in 2008, the number of fatal accidents peaked at 9. This accident record is cause for concern. However, a lack of reliable data on flight hours precludes calculation of the industry accident rate--a critical piece of information in determining whether the increased number of accidents reflects industry growth or a declining safety record. The air ambulance industry and FAA have acted to address accident trends and causes. For example, FAA enhanced its oversight to reflect the varying sizes of operators, provided technical resources to the industry, launched an accident mitigation program, and revised the minimum standards for weather and safe cruising altitudes that apply to air ambulance operations. Despite the actions to improve air ambulance safety, 2008 was the deadliest year on record for the industry. Through its work on aviation safety, including air ambulance safety; review of the published literature; and interviews with government and industry officials, GAO has identified several potential strategies for improving air ambulance safety, including the following: (1) Obtain complete and accurate data on air ambulance operations. (2) Increase the use of safety technologies. (3) Sustain recent efforts to improve air ambulance safety. (4) Fully address NTSB's recommendations. (5) Adopt safety management systems within the air ambulance industry. (6) Clarify the role of states in overseeing air medical services. (7) Determine the appropriate use of air ambulance services.

section_title: Letter
paragraphs: I appreciate the opportunity to testify before you today on air ambulance  safety. My remarks will focus on (1) recent trends in the air ambulance  industry with regard to size, composition, and safety record; (2) recent  industry and government efforts to improve air ambulance safety; and (3)  potential strategies for improving air ambulance safety. My testimony is  based primarily on our February 2007 report on air ambulance safety,  which we conducted at the request of the Chairman. To update and  supplement our existing work, we analyzed the latest safety information  from the National Transportation Safety Board (NTSB) and the Federal  Aviation Administration (FAA), reviewed published literature on the state  of the air ambulance industry, and interviewed officials from NTSB and  FAA and industry representatives.  We conducted this work in March and  April 2009.
subsections: section_title: Background
paragraphs: Air ambulances are an integral part of U.S. emergency medical systems,  primarily transporting patients between hospitals, but also providing  transport from accident scenes or for organs, medical supplies, and  specialty medical teams. Air ambulances may be helicopters or fixed-wing  aircraft. Helicopter air ambulances provide on-scene responses and much  of the shorter-distance hospital-to-hospital transport, while fixed-wing  aircraft are used mainly for longer facility-to-facility transport. (See fig. 1.)  Helicopter air ambulances make up about 74 percent of the air ambulance  fleet and, unlike fixed-wing aircraft, do not always operate under the  direction of air traffic controllers. They also often operate in challenging  conditions, flying, for example, at night during inclement weather and  using makeshift landing zones at remote sites. My testimony today focuses  on the safety of helicopter air ambulance operations.
Air ambulance operations can take many different forms but are generally  one of two business models—hospital-based or stand-alone. 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. The hospital pays the operator for services supplied. In a  stand-alone (independent or community-based) 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  either employs both the medical and flight crews or contracts with an  aviation services provider for them. This stand-alone model carries more  financial risk for the operator because revenues depend solely on  payments for transporting patients. Some operators provide both hospital- based and stand-alone services and may have bases located over wide  geographic areas.
Regardless of the business model employed, most air ambulances—except  government and military aircraft—must operate under rules specified in  Part 135 of Title 14 of the Code of Federal Regulations when patients are  on board and may operate under rules specified in Part 91 when patients  are not present. As a result, different legs of air ambulance missions may  be flown under different rules. However, some operators fly under part  135 regardless of whether patients are on board the aircraft. (See fig. 2.)  Flight rules under Parts 91 and 135 differ in two key areas—(1) minimum  requirements for weather and visibility and (2) rest requirements for  pilots. The Part 135 requirements are more stringent.
section_title: Industry Has Expanded and Safety Concerns Have Grown in Recent Years
subsections: section_title: Available Data Suggest Industry Growth and Increased Competition
paragraphs: According to industry experts and observers, the air ambulance industry  has grown, but data limitations make it difficult to determine by how  much. Data for several years on the 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 the  Association of Air Medical Services (AAMS). For 2003, the first year for  which data are available, AAMS members reported a total of 545  helicopters stationed at 472 bases (airports, hospitals, and helipads). By  2008, the number of helicopters listed in the database had grown to 840, an  increase of 54 percent, and the number of bases had grown to 699, an  increase of 48 percent (see fig. 3). While a database official said that the  data partly reflect the use of a revised criterion that allowed for the  inclusion of more helicopters and for improved reporting since the  database was established, the increase also reflects actual growth.
Data are less readily available on whether this increase number of 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 operators regulated under Part  135 are not required to report flight activity data to FAA or the Department  of Transportation. Historically, FAA estimated the number of flight hours,  using responses to its annual General Aviation and Air Taxi and Avionics  (GAATAA) survey. These estimates may not be reliable, however, because  the survey is based on a sample of aircraft owners and response rates have  historically been low.
According to the government and industry officials we interviewed and the  literature we reviewed, most of the air ambulance industry’s growth has  been in the stand-alone (independent) provider business model.  Testimony from industry stakeholders recently submitted to NTSB further  identifies the stand-alone provider business model as the current area of  industry growth. The growth in the stand-alone provider business model  has led to increased competition in some locales. According to the  officials we interviewed and others who have studied the industry, the  increase in the stand-alone provider business model is linked to the  development, mandated in 1997, of a Medicare fee schedule for ambulance  transports, which has increased the potential for profit making. This 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. Because the fee schedule has created the  potential for higher and more certain revenues, competition has increased  in certain areas, according to many of our sources.
Increased competition can lead to potentially unsafe practices, industry  experts said. Although we were unable to determine how widespread  these activities are, experts cited the potential for such practices,  including helicopter shopping and call jumping. Helicopter shopping refers  to calling a series of operators until an operator agrees to take a flight  assignment, without telling the subsequently called operators why the  previously called operators declined the flight. This practice can be unsafe  if the operator that accepts the flight assignment is not aware of all of the  facts surrounding the assignment. Call jumping occurs when an air  ambulance operator responds to a scene without being dispatched to it 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 at night or in marginal weather  conditions—increasing the risk of a midair collision or other accident.
section_title: Industry Experienced Highest Number of Fatal Accidents in 2008, but Data Limitations Preclude Complete Understanding of Safety Record
paragraphs: From 1998 through 2008, the air ambulance industry averaged 13 accidents  per year, according to NTSB data. The annual number of air ambulance  accidents increased from 8 in 1998 to a high of 19 in 2003. Since 2003, the  number of accidents has slightly declined, fluctuating between 11 and 15  accidents per year. While the total number of air ambulance accidents  peaked in 2003, the number of fatal accidents peaked in 2008, when 9 fatal  accidents occurred (see fig. 4). Of 141 accidents that occurred from 1998  to 2008, 48 accidents resulted in the deaths of 128 people. From 1998  through 2007, the air ambulance industry averaged 10 fatalities per year.  The number of overall fatalities increased sharply in 2008, however, to 29.
Both the spike in the number of fatal accidents in 2008 and the overall  number of accidents are a cause for concern. However, given the apparent  growth in the industry, the increase in the number of accidents may not  indicate that the industry has experienced, on the whole, the industry’s  safety record has worsened. More specifically, without actual data on the  number of hours flown, no accident rate can be accurately calculated.  Because an accurate accident rate is important to a complete  understanding of the industry’s safety, we recommended in 2007 that FAA  collect data on flight activity, including flight hours. In response, FAA has  surveyed all helicopter air ambulance operators to collect flight activity  data. However, to date, FAA’s survey response rate is low, raising  questions about whether this information can serve as an accurate  measure or indicator of flight activity.
In the absence of actual flight activity data, others have attempted to  estimate flight hours and accident rates for the industry. For example, an  Air Medical Physician Association (AMPA) study estimated annual flight  hours for the air medical industry through an operator survey, determining  that the overall air medical helicopter accident rate has dropped slightly in  recent years to approximately 3 accidents per 100,000 flight hours.  However, the study’s preliminary estimates for 2008 indicate that the fatal  accident rate tripled over the 2007 rate, increasing from 0.54 fatal  accidents per 100,000 flight hours in 2007 to 1.8 fatal accidents per 100,000  flight hours in 2008.
Data on the causes and factors underlying air ambulance accidents  indicate that while the majority of accidents are caused by pilot error, a  number of risks, including nighttime operations, adverse weather  conditions, and flights to remote sites, also contribute to accidents. NTSB  data on helicopter accidents occurring from 1998 through 2008 show that  pilot error was deemed the probable cause in more than 70 percent of air  ambulance accidents, while factors related to flight environment (such as  light, weather, and terrain) contributed to 54 percent of all accidents.  Nighttime accidents for air ambulance helicopters were prevalent, and air  ambulance accidents tended to be more severe when they occurred at  night than during the day. Similarly, air ambulance accidents were often  associated with adverse weather conditions (e.g., wind gust and fog).  Finally, flying to remote sites may further expose the crew to other risks  associated with unfamiliar topography and makeshift landing sites.
section_title: Industry and FAA Have Acted to Address Air Ambulance Accident Trends and Causes
subsections: section_title: Increase in Number of Accidents Has Led to Greater Industry Focus on Safety
paragraphs: In 2007, we reported that the air ambulance industry’s response to the  higher number of accidents has taken a variety of forms, including  research into accident causes and training. Since then, the industry has  continued its focus on improving safety by, for example, initiating efforts  to develop an industry risk profile and share weather information. In July  2008, for instance, AAMS convened a conference (summit) on safety to  encourage open communication between the medical and aviation sectors  of the industry. AAMS plans to issue a summary of the summit’s  proceedings that will include recommended next steps. Table 1 highlights  examples of recent industry initiatives.
section_title: FAA Has Taken a Number of Actions to Address Safety Concerns
paragraphs: In 2007, we reported that FAA, the primary federal agency overseeing air  ambulance operators, has issued guidance, expanded inspection  resources, and collaborated with the industry to reduce the number of air  ambulance accidents. Since then, FAA has taken additional steps to  improve air ambulance safety including the following:    Enhanced oversight to better reflect the unique nature of the  industry. FAA has changed its oversight to reflect the varying sizes of  operators. Specifically, large operators with 25 or more helicopters  dedicated to air medical flights are now assigned to dedicated FAA  Certificate Management Teams (CMT)—groups of inspectors that are  assigned to one air ambulance operator. These CMTs range in size from 4  inspectors for Keystone Helicopter Corporation, which has a fleet of 38  helicopters, to 24 inspectors for Air Methods, which has a fleet of 322  helicopters. Additionally, CMTs use a data- and risk-based process to  target inspections to areas that pose greater safety risk. For operators of  all sizes, FAA has asked inspectors to consider using the Surveillance  Priority Index tool, which can be used to identify an operator’s most  pressing safety hazards. In addition, FAA is hiring more aviation safety  inspectors with rotorcraft experience.
Provided technical resources. FAA has revised its guidance for the use  of night vision goggles (NVG) and established a cadre of NVG national  resource inspectors. FAA has also developed technical standards for the  manufacture of helicopter terrain awareness and warning systems for air  medical helicopters. These standards articulate the minimum  performance standards and documentation requirements that the  technology must meet to obtain FAA approval. FAA also commissioned  the development of an air ambulance weather tool, which provides  weather assessments for the community.
Launched accident mitigation program. Initiated in January 2009, this  program provides guidance for inspectors of air ambulance operators,  requiring them to ensure, among other things, that these operators have a  process in place to facilitate safe operations, such as a risk assessment  program.
Revised minimum standards for weather and safe cruise altitudes:  To enhance safety, FAA revised its minimal requirements for weather and  safe cruise altitudes for helicopter air ambulances in November 2008.  Specifically, FAA revised its specifications to require that if a patient is on  board for a flight or flight segment and at least one of the flight segments  is therefore subject to Part 135 rules, then all of the flight segments must  be conducted within the revised weather minimums and above a minimum  safe cruise altitude determined in preflight planning.
Issued guidance on operational control: To help operators better  assess risk, improve the flow of information before and during flights, and  increase support for flight operations, FAA issued guidance to help air  medical operators develop, implement, and integrate operations control  centers and enhance operational control procedures.
To date, FAA has opted not to use its rulemaking authority to require  certain actions, relying instead on notices and guidance to encourage air  ambulance operators to take certain actions. FAA guidance and notices  are not mandatory for air ambulance operators and are not subject to  enforcement. FAA officials told us that rulemaking 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. However, we previously noted that FAA lacked  information on the extent to which air ambulance operators were  implementing the agency’s voluntary guidance and on the effect such  guidance was having. Consequently, we recommended that FAA collect  information on operators’ implementation of the voluntary guidance and  evaluate the effectiveness of that guidance. In response, in January 2009,  FAA directed safety inspectors to survey the air medical operators they  oversee about their adoption of suggested practices, such as implementing  risk assessment programs and developing operations control centers.  According to the inspectors, most of the 74 operators surveyed said they  had adopted these practices.
section_title: Potential Strategies for Improving Air Ambulance Safety
paragraphs: Despite the actions taken by the industry and the federal government, 2008  was the deadliest year on record for the air ambulance industry. As a  board member noted at the recent NTSB hearing on air ambulance safety,  the recent accident record of the industry is unacceptable. Based on our  body of work on aviation safety, including air ambulance safety; a review  of the published literature; and interviews with government and industry  officials, we have identified several potential strategies for improving air  ambulance safety. Each of these strategies has merits and challenges, and  we have not analyzed their benefits and costs. But, as the recent accident  numbers show, additional efforts are warranted.
Obtain complete and accurate data on air ambulance operations: As  we reported in 2007, FAA lacks basic industry information, such as the  number of flights and flight hours. In response to our prior  recommendation that FAA collect flight activity data, FAA surveyed all  helicopter air ambulance operators in 2008, but fewer than 40 percent  responded, thereby raising questions about the reliability of the  information collected. The low response rate also suggests that many  operators will not provide this information unless they are required to do  so. Until FAA obtains complete and reliable information from all air  ambulance operators, it will be unable to gain a complete understanding of  the industry and determine whether its efforts to improve industry safety  are sufficient and accurately targeted.
Increase use of safety technologies: We have previously reported that  using appropriate technology and infrastructure can help improve aviation  safety. For example, the development and installation of terrain  awareness and warning systems on large passenger carriers has almost  completely eliminated controlled flights into terrain, particularly for  aircraft equipped with this system. When we studied the air ambulance  industry in 2006 and 2007, the most frequently cited helicopter-appropriate  technology was night vision goggles. Additional safety technology has  been developed or is in development that will help aircraft avoid cables  and enhance terrain awareness for pilots, among other things. However,  testimony submitted by industry stakeholders at NTSB’s February 2009  hearing on air ambulance safety indicated that the implementation of such  technology has been slow. NTSB previously recommended that FAA  require terrain awareness and warning systems on air ambulances.  Proposed legislation (H.R. 1201) would also require FAA to complete a  study within one year of the date of enactment on the feasibility of  requiring flight data and cockpit voice recorders on new and existing air  ambulances.
Sustain recent efforts to improve air ambulance safety: Our past  aviation safety work and anecdotal information on air ambulance accident  trends suggest that the industry and federal government must sustain  recent efforts to improve air ambulance safety. In 1988, after the number  of accidents increased in the mid-1980s, NTSB published a study that  examined air ambulance safety issues. The study contained 19 safety  recommendations to FAA and others. FAA took action, including  implementing the NTSB recommendations, and the number of ambulance  accidents declined in the years that immediately followed. However, as  time passed, the number of accidents started to increase, peaking in 2003.  This again triggered a flurry of government and industry actions. Similarly,  FAA took steps to address runway incursions and overruns after the  number and rate of incursions peaked in fiscal year 2001, but FAA’s efforts  later waned, and the number and rate of incursions and overruns remained  steady.
Fully Address NTSB recommendations: In 2006, NTSB published a  special report focusing on the air ambulance industry, which included four  recommendations to FAA to improve air ambulance safety. Specifically,  NTSB called for FAA to (1) require that all flights with medical personnel  on board be conducted in accordance with Part 135 regulations, (2)  develop and implement flight risk evaluation programs, (3) require  formalized dispatch and flight-following procedures, and (4) require  terrain awareness and warning systems on aircraft. As of January 2009,  FAA had sufficiently addressed only the recommendation to require  formalized dispatch and flight-following procedures, according to NTSB.  However, NTSB’s February 2009 air ambulance hearing highlighted the  status of the NTSB recommendations, and major industry associations  have said they agree in principle with the recommendations, but would  like to work with FAA and NTSB to adapt the recommendations to the  industry’s circumstances and gain more flexibility. Proposed legislation  (H.R. 1201) also would require most of the safety enhancements NTSB  recommended.
Adopt safety management systems within the air ambulance  industry: Air operators rely on a number of protocols to help reduce the  potential for poor or erroneous judgment, but evidence suggests that these  protocols may be inconsistently implemented or followed in air ambulance  operations. According to an FAA report on air ambulance accidents from  1998 through 2004, a lack of operational control (authority over initiating,  conducting, and terminating a flight) and poor aeronautical decision  making were significant factors contributing to these accidents. To  combat such issues, FAA has been encouraging air ambulance operators  to move toward adopting safety management systems, providing guidance,  developing a generic flight risk assessment tool for operators, and  requiring inspectors to promote the adoption of safety best practices.
Clarify the role of states in overseeing air ambulance services: Air  ambulance industry stakeholders disagree on the role that states should  play in overseeing broader aspects of air medical operations. In particular,  some industry stakeholders have advocated a greater role for states in  regulating air ambulance services as part of their public health function.  Other industry stakeholders, however, oppose increased state oversight,  noting, for example, that the Airline Deregulation Act explicitly prohibits  states from regulating the price, route, or service of an air carrier. This  legislation generally limits oversight at the state or local levels to the  medical care and equipment provided by air ambulance services, although  the extent of this oversight varies by state. Proposed legislation (H.R. 978)  would recognize and clarify the authority of the states to regulate  intrastate air ambulance services in accordance with their authority over  public health.
Determine the appropriate use of air ambulance services: According  to a May 2007 article by two physicians, multiple organizations are  concerned that air ambulance services are overused and misused. The  study further notes concerns that decisions about where to transport a  patient may be influenced by nonmedical reasons, such as insurance  coverage or agreements with hospitals. Another industry expert has  posited that excessive use of air ambulances may be unsafe and not  beneficial for most patients, citing recent studies that conclude few air  transport patients benefited significantly over patients transported by  ground and noting the recent increase in the number of air medical  accidents. Other studies, however, have disagreed with this position, citing  reductions in mortality achieved by using air ambulances to quickly  transport critically injured patients.
section_title: Agency Comments
paragraphs: We provided a draft copy of this testimony to FAA for review and  comment. FAA provided technical clarifications, which we incorporated  as appropriate.
Mr. Chairman, this concludes my prepared statement. I would be pleased  to respond to questions from you or other Members of the Subcommittee.
section_title: GAO Contact and Staff Acknowledgments
paragraphs: For further information on this statement, please contact Dr. Gerald L.  Dillingham at (202) 512-2834 or dillinghamg@gao.gov. Contact points for  our Congressional Relations and Public Affairs offices may be found on  the last page of this statement. Individuals making key contributions to  this testimony were Nikki Clowers, Assistant Director; Vashun Cole,  Elizabeth Eisenstadt, Brooke Leary, and Pamela Vines.
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