Air Ambulance Safety Concerns

Last year was a particularly deadly one for flight crews and patients, with 18 people killed in 11 accidents, the highest number of deaths in a year in more than a decade, according to federal regulators and an industry group. The spike is putting a spotlight on a little-regulated and fast-growing sector of health care: the medical helicopter industry. There are an estimated 700 medical helicopters operating nationally, about twice the number flying a decade ago.

Emergency medical helicopters do save lives, by speeding some patients to hospitals far faster than a ground ambulance could and by reaching remote areas. But the industry's rapid, competitive growth may also be exacting a toll. Federal regulators and some doctors worry that the pool of skilled helicopter pilots has become drained and that some of those flying are making poor decisions. In addition, some companies are flying older helicopters that lack the instruments needed to help pilots navigate safely. Of the 27 fatal medical helicopter accidents that occurred between 1998 and 2004, 21 were at night and often in bad weather, according to federal statistics.

Last month, the Federal Aviation Administration, after a meeting with helicopter operators, proposed steps to improve flight safety. They included helping pilots assess risks and providing them with up-to-date electronic equipment like radar altimeters, night-vision goggles and terrain awareness warning systems, among other things. In addition, it recommended that companies emphasize a "safety culture" and also improve systems that will give pilots better information about changing weather conditions while they are in flight. Separately, the National Transportation Safety Board has been examining medical helicopter safety and plans to issue recommendations to the Federal Aviation Administration, a safety board official said.

Initial reviews by the aviation agency and the safety board indicate that pilot error was to blame in many of the recent accidents. A report in 1988 by the board, which came after a string of accidents in the preceding years, found that medical helicopters were crashing at a rate three times higher than that of other helicopters. At that time, the safety board made a number of recommendations adopted by the aviation agency, including better pilot training, particularly for flying in bad weather.

Executives of medical helicopter companies and trade groups said they were greatly concerned by the rising accident numbers but added that the figures might simply reflect the fact that more helicopters were flying, rather than an increase in the accident rate. The executives said they could not be sure a trend existed because the industry had been operating without a system to track its total flight hours, a standard measure for assessing air deaths. Under pressure from regulators, company officials say they hope to have such a database in place by late spring, and several asserted that they were not pressuring pilots to take on dangerous missions.

The growing concerns about medical helicopter safety are unfolding alongside a long-running debate over whether many such flights are medically necessary. The cost of a medical airlift typically ranges from $5,000 to $8,000, five or more times that of a traditional ambulance. Private health plans and some public ones, like Medicare, cover air services, at least in part. There are about 350,000 medical helicopter flights annually, with about 30 percent involving calls to accidents or other emergencies, according to the Association of Air Medical Services, a trade group in Alexandria, Va. Most other flights involve the transfer of patients between hospitals.

As recently as a decade ago, medical helicopters were generally operated directly by hospitals and emergency service units or run under arrangements with aviation companies which provided the helicopters and pilots. But industry officials said the business began to change in the late 1990's when the federal government required hospitals to charge separately for ambulance services, including airborne ones, rather than bundling such costs in bills paid by all patients. In addition, Medicare, in adopting a national fee schedule, increased reimbursement rates for air ambulance flights in some regions. As a result, many hospitals decided to abandon their helicopter operations, and for-profit companies saw an opportunity.

The splintering in the way the industry operates has led to a hodgepodge of standards. For example, the Mayo Clinic, which gets its craft and crews from an aviation company, requires pilots to have 5,000 hours of experience and uses only twin-engine helicopters. Air Evac requires pilots to have 1,500 hours of flight time before hiring them and uses older single-engine craft.

-Adapted from “Crashes Start Debate on Safety of Sky Ambulances” by Barry Meier, The New York Times, February 28, 2005.

02/2005