The first hospital air medical program was established in 1972. In the following years, the air medical industry underwent tremendous growth, from that one program in 1972, to 32 in 1980, and 101 by 1985. ⁶ With this growth came the realization that air medical helicopters had an accident rate far greater than that of helicopters engaged in general aviation.

From 1980 to 1985, the helicopter emergency medical services (HEMS) industry had an estimated accident rate of 12.3 accidents/100,000 patients transported. The accident rate for nonscheduled turbine-powered air taxi helicopter operators, a comparable non-HEMS population, was 6.9/100,000 for the same time period. ⁴⁷ In 1988, the NTSB released the results of its investigation of 59 Emergency Medical Services (EMS) accidents that occurred between 1978 and 1986. The study concluded that weather-related accidents were the most common and most serious type of accident experienced by EMS helicopters. ⁴⁷

The 1990s showed continued growth in the air medical industry, from an estimated 174 HEMS programs operating 232 helicopters in 1990 to 225 programs operating 360 helicopters in 1999. ⁶ In 1990, one accident occurred with no fatalities. During the next 5 years, an average of 5.5 accidents per year occurred. In 1996, only one HEMS accident again was seen, this one fatal, and three were seen in 1997. During the period from 1998 to 2001, the accident rate increased sharply to an average of 10.8 HEMS accidents per year. ⁶ A review of 121 air medical accidents from the late 1970s through the late 1990s found weather-related accidents to be the most common type, with an increase of 10% from the 1980s to the 1990s. ^{22.23. and 24.}

In 2002, the Air Medical Physicians Association (AMPA) released A Safety Review and Risk Assessment in Air Medical Transport, which examined HEMS accidents from 1980 to 2001. ⁶ This report looked not only at the total yearly numbers of accidents but also at accident, injury, and fatality rates as functions of the number of EMS aircraft operating, the number of patients transported, and the estimated total flight hours for each year. The analysis showed a generally decreasing trend in number of HEMS accidents per 100,000 patient transports from the high in 1982 of 24.9/100,000 (a higher rate than that calculated by the NTSB in 1988) to a low in 1996 of 0.57/100,000. The average for the last 5 years of the study (1997 to 2001) was 4.6/100,000 patient transports. The most common recurrent factors in HEMS accidents were again found to be poor weather conditions and operations at night.

In 2003, the year after the publication of the AMPA study, there were 18 HEMS accidents, four of which were fatal. The year 2004 had 13 accidents, and 2005 had 17, with six fatal accidents each year. In January 2006, the NTSB released an Aviation Special Investigation Report that examined 55 EMS aircraft accidents that occurred between January 2002 and January 2005, 41 of which were helicopter accidents. ⁴⁸ The investigation identified these recurrent safety issues:

Also in 2006, Baker et al⁵ reviewed HEMS accidents for the period from 1983 to 2005 to determine the factors related to fatal outcomes. They concluded that accidents that occur at night or in bad weather or that result in a postimpact fire have a higher risk of being fatal. ⁵

In 2006, a total of seven HEMS accidents occurred, three with fatalities, and in 2007, six accidents occurred, two of which were fatal. The year 2008 brought the worst year in the industry’s history for fatal accidents, with a total of 12 HEMS accidents from January to November 2008, including the first-ever mid-air collision of two helicopter air ambulances (included in these totals as two accidents). Nine of these accidents were fatal, claiming a total of 29 lives, including five patients. ^11,26,46 In 2008, 264 HEMS programs were in the United States, operating 699 helicopter bases and a total of 840 helicopters, ⁴ more than twice the number of aircraft in operation in 1999. Figure 9-1 summarizes accidents from January 1980 to November 2008.

Fixed-wing air medical accidents have not been as well studied as HEMS accidents. In 2008, 108 air medical programs listed in the Atlas and Database of Air Medical Services (ADAMS) operated a total of 292 fixed-wing aircraft. ⁴ Sixty-two of these programs operated both fixed-wing aircraft and helicopters. A review of accident data from 2002 to November 2008 showed a total of 14 accidents from 2002 to 2006, six of which were fatal. In 2007, six fixed-wing air medical accidents occurred, four of which were fatal; none were found in 2008. ^11,26,45,48

The data presented do not pretend to paint the whole picture of accident risk in air medical transport. The actual rates and the causes of air medical accidents are continuing topics of intense study and debate. ³ Although specific numbers and root causes may not always be clear, what is clear is that we continue to have accidents and that patients and flight crews continue to be injured and killed. Also clear is that recurrent factors continue to be involved in air medical accidents, most notably operations at night and in inclement weather. We need to maintain a respect for these hazards and promote (and use) every tool and practice available to reduce the risks of flight in the HEMS environment.

The same level of attention paid to air medical accidents has not been paid to ground ambulance accidents. Unlike air medical accidents, which must be reported and are investigated by the NTSB, ground ambulance crashes are generally monitored on a state or local level, which makes consistent nationwide data difficult to obtain. In 2001, Kahn et al³⁰ published a review of all reported fatal US ambulance crashes from 1987 to 1997. The 339 fatal accidents resulted in 405 fatalities and 838 injuries. Those victims in the rear compartment who were unrestrained or improperly restrained had the most severe injuries and fatalities. Most of the crashes (202/339), and fatalities (233/405), occurred during emergency operations. The most common crash location was at an intersection. ³⁰ The Centers for Disease Control (CDC) reported in 2003 on 300 fatal ambulance crashes that occurred from 1991 to 2003. These crashes resulted in the deaths of 27 on-duty EMS workers, 55 other occupants of the ambulances, and 275 occupants of other vehicles and pedestrians. Most of the EMS worker fatalities (60%) occurred in the front of the vehicle. ³⁹

These studies show that ground ambulance accidents also have recurrent contributing factors. Safety training programs should focus on awareness of these risks, safe driving, and proper use of safety equipment, such as seatbelts. Ground transport programs need to establish the same safety culture and have the same commitment to safety and risk reduction as air medical programs.

Since the 1980s, efforts have been made to reduce the risks of flight in the air medical environment. These efforts at risk reduction have taken many forms, from safety policies and procedures, to training and new technologies.

All reviews of air medical accidents have identified the same two environments as significant contributing factors: operations at night and during bad weather. These two environments have one major factor in common: reduced visibility. A variety of technologies can reduce the risk of operating during reduced visibility conditions by supplying additional information about potential hazards in the flight environment. One of the recurrent safety issues identified in the 2006 NTSB report was the lack of requirements that air medical aircraft make use of these safety technologies to enhance flight safety.

The Air and Surface Transport Nurses Association (ASTNA, formerly the National Flight Nurses Association [NFNA]) has long been a safety advocate and has published a series of position papers related to air medical safety. ASTNA is a professional nursing organization with a membership that includes transport nurses from throughout the United States and Canada. In 1988, the NFNA (ASTNA) published the position paper Improving Flight Nurse Safety in the Air Medical Helicopter Environment. In this paper, the organization endorsed many of the recommendations of the NTSB study published earlier the same year. The NFNA stated that “available knowledge and technology which could significantly enhance [a] flight nurse’s safety in the air medical helicopter environment is not consistently applied and utilized in all air medical transport programs.”⁴² The position paper proposed several corrective measures. The proposals dealt with: (1) crew scheduling and rest periods; (2) the right of flight nurses to refuse to participate in a flight as a result of concerns for personal safety; (3) the need for programs to develop written protocols for the use of physical and pharmacologic restraints when combative or potentially combative patients are transported; (4) the need for programs to critically evaluate hot-loading and unloading policies and procedures and to ensure personnel assigned to hot load or unload do so only after proper training; and (5) the adoption of measures to maximize safety and reduce the potential of serious injury with use of helicopter design changes such as energy-attenuating seats, addition of shoulder harnesses to lap belts at each position in the aircraft, and development and installation of crash-resistant fuel systems in aircraft as soon as possible.

The 1988 NFNA position statement also dealt with specific in-flight duties to be performed by flight nurses to ensure a safe aviation environment. These responsibilities included: (1) securing equipment during flight; (2) use of seat belts and shoulder harnesses; (3) properly securing patients within the aircraft; (4) judicious use of night lighting; and (5) isolation of the pilot and controls from potential patient movement.

In 1998, the NFNA position paper was updated and expanded to include the following recommendations: (1) that flight nurses interact more with the PIC, participating in recurrent safety, premission, and postmission briefings; being taught how to report aircraft position; and undergoing crew member emergency training; (2) use of appropriate personal protective gear, including helmets, flame-resistant flight uniforms, and protective footwear; (3) stress-management programs to enhance flight nursing performance; and (4) use of back-up aircraft that are similar to the primary aircraft in the flight program. ⁴² These recommendations have since become part of routine operations for a large portion of the air medical industry.

In 2006, a third revision, Transport Nurse Safety in the Transport Environment, was published. It reinforced the positions stated in the first two editions of the paper and updated them to reflect the safety concerns of the medical transport industry in the early 21st century. The paper also expanded its focus to apply to transport nurses in all practice settings, including helicopter, fixed-wing, and ground patient transport. ¹

In 1990, the Commission for Accreditation of Medical Transport Systems (CAMTS) was established. The CAMTS accreditation standards require that “There is evidence that safety issues are addressed specific to the operational environment (i.e., weather, terrain, aircraft performance).” CAMTS standards also contain recommendations and requirements for weather minimums, safety management programs, accident/incident reporting, and pilot and flight crew training. ¹²

The Air Medical Safety Advisory Council (AMSAC) was organized by the Association of Air Medical Services (AAMS) in 2002 at the request of the FAA to address the increasing rate of air medical accidents. AMSAC is composed of representatives from AAMS, NEMSPA, ASTNA, FAA, National Aeronautics and Space Administration (NASA), insurance companies, and other industry groups. It serves as a forum to discuss the safety issues and concerns of the air medical community, including flight and duty time, fatigue countermeasures, minimum flight time standards, AMRM, data collection, accident/incident reporting, and shared critical maintenance information. A focus area for AMSAC has been the potentially negative effect of interprogram competition. ³⁵

In 2005, AAMS, in cooperation with many other organizations, launched the Vision Zero Initiative “to reduce and eliminate errors of consequence—those events within the transport medicine environment that result in serious injury or fatality”³ by 80% in 10 years. The Vision Zero Initiative is intended to foster communication and cooperation between all aspects of the medical transport industry (safety organizations, professional associations, trade organizations, and regulatory agencies) to develop voluntary and regulatory measures to achieve the stated goals. ³

Voluntary safety reporting systems encourage individuals, transport programs, and aviation certificate holders to voluntarily report safety issues, concerns, and events. By submitting voluntary reports, programs and individuals may identify safety issues that affect more than just their program or agency and permit others to learn from their experience. The CONCERN Network (http://concern-network.org) is a voluntary reporting system whose purpose is “to increase awareness of safety hazards in the medical transport community.” Transport programs submit reports of accidents or incidents, and bulletins are then distributed via e-mail to CONCERN Network subscribers and maintained in an online archive. ¹¹ Transport team members may also submit anonymous reports. The FAA’s Aviation Safety Action Program (ASAP) is designed to improve safety throughout the aviation industry. It allows participants to submit confidential reports that “identify actual or potential risks throughout their operations.” All of the parties involved can then work together to develop or update operational practices to reduce the risk of accidents and other safety-related events. ¹⁸

The Safety Committee should be composed of representatives of all disciplines involved in the transport program: aviation, clinical, maintenance, communications, and administration. The committee should meet at least quarterly to address safety issues, practices, concerns, or questions. Reports of the committee’s discussions and actions should be sent to the program’s management and kept on file.

Other duties of the Safety Committee include planning and presenting annual safety training, interacting with the program’s continuous quality improvement (CQI) and risk management systems, and tracking safety-related events. Information that results from the decisions and recommendations made by the Safety Committee should be communicated appropriately and, when indicated, incorporated into the program’s policies, procedures, and operations.

Personal safety is an important aspect of the safety attitude. For the individual crew member, personal safety is the mindset, habits, and daily practices that keep that individual safe. Each member of the transport team also bears the responsibility for the personal safety of others, including partner, pilot, patient, and fellow responders. For the transport service, personal safety means providing a safe work environment, appropriate personal protective equipment, and safety training and also involves establishing and following safety standards and policies. The best safety training and equipment in the world are of little value if not used properly, and safety standards cannot be effective if they are not followed.

The 1988 NTSB study recommended that air medical personnel who routinely fly EMS helicopter missions wear protective clothing and equipment to reduce the chance of injury or death in survivable accidents. ²⁵ The ASTNA position papers have also endorsed the use of protective equipment. Protective equipment consists of helmets, fire-resistant uniforms, and boots.