(20) Based on industry flighthour estimates, growth in the use of air ambulances has been increasing at a rate of about 4.5% peryear over the past 15 years, and most observers believe that this steady growth in both the size of thededicated air ambulance fleet in the United States and the utilization of air ambulances will continueover the next several years. Pilot knowledge or "situation awareness" regarding weather conditions and terrain has also been found to be a significant factor in a large number of air ambulance accidents. Pilot Situation Awareness of Weather Conditions. In its most recent review of air ambulance safety, the NTSB found that situation awareness can oftenbe lacking in air ambulance operations for a variety of reasons, but was chiefly concerned with thelack of formal flight dispatch procedures among operators. However, neither the FAA nor theNTSB has identified maintenance practices among air ambulance aircraft as a specific area forconcern. Consequently, present efforts to prevent air ambulance crashes are focused, instead, on riskfactors associated with flight operations and pilot performance. Options for Improving Safety

Based on available data summarized above suggesting that flight operational factors are thecentral cause of the large majority of air ambulance accidents, options for improving safety havefocused on possible changes to flight operations and practices among air ambulance operators. These various options have been framed in terms of possible alternatives for changing regulatorystandards and oversight of air ambulance operators, incorporating system safety and riskmanagement principles into the decision making processes regarding air ambulance missions,providing additional or supplemental training for flight crews as well as medical crews, andincorporating various technologies to aid pilots and improve safety in low visibility conditions. The NTSB also noted that when patients are not on board, forexample during positioning flights or en route to an accident scene, air ambulance operators mayoperate under a less stringent set of regulations, because the FAA regards medical personnel onboard as essential crew members. Therefore, in addition to addressing the broaderquestion of whether air ambulance flights should adhere to commercial flight regulations during allphases of a mission, including times when patients are not on board, policymakers may considerpossible changes in pilot duty time and flight time regulations to address concerns over the potentialrole of fatigue in the safety of flight operations. As previouslymentioned, little attention has been given to the oversight of maintenance practices at facilities thatmaintain and repair air ambulance aircraft. Aircraftcrashworthiness and accident survivability is another regulatory issue that hasn't received muchattention with regard to air ambulance safety. (50) While theseefforts suggest that the industry as a whole is concerned about the current level of safety among airambulance operators and desires to take positive steps to improve safety, some, including the NTSB,argue that voluntary measures to improve safety such as this are insufficient, and certainsafety-related changes such as formal dispatch procedures and risk management practices shouldrequire mandatory, industry-wide compliance. (53) 
In the airline industry, several initiatives to improve the collection and analysis ofsafety-related operational data have taken root and are now common practice. (62) 

		Technology to Improve Safety in Low Visibility Conditions

Various technologies are available to improve visibility and pilot situation awareness ofterrain, obstacles, and weather. Terrain Warning Systems.
The estimated rate of air ambulance accidents has been steadily rising since the early 1990s,and has increased at a rapid rate since 1998 when the industry began to expand more rapidly and shifttoward a model of more independent private air ambulance services that cover larger geographicareas. Statistics indicate that the large majority of air ambulance accidents are attributable tooperational factors related to pilot situation awareness and decision making when faced with adverseenvironmental conditions such as darkness, deteriorating weather, rugged terrain, or somecombination of these factors.
Initiatives to improve air ambulance safety to date have consequently focused on additionalpilot training, implementing risk management practices to improve the safety of flight operations,and using various technologies to improve pilot situation awareness in restricted visibility conditions. However, implementation of these safety measures has strictly been voluntary. The NationalTransporation Safety Board (NTSB) and other aviation safety experts are advocating the mandatoryuse of formal flight dispatch procedures and risk management practices among air ambulanceoperators as well as mandatory installation of terrain warning systems on air ambulance aircraft. TheNTSB also found that many air ambulance accidents occur when patients are not on board, such asen route to an accident scene. Present regulations allow air ambulances to operate under a lessstringent set of rules with regards to weather minimums and pilot duty times when not carryingpatients. However, the NTSB believes that air ambulance flights should operate under morestringent commercial operating rules at all times that medical personnel are carried on board. Although maintenance issues have been identified in about 20 percent of all air ambulance accidents,neither the Federal Aviation Administration (FAA) nor the NTSB has placed any specific emphasison oversight of operators or repair stations that maintain air ambulance aircraft. The presentemphasis on air ambulance safety has, instead, been dominated by concerns over flight crewperformance and weather-related factors.
A variety of options are available to improve safety among air ambulance operators. Theseoptions include intensified oversight of air ambulance operators and regulatory changes to bring allphases of air ambulance operations under the same set of operational rules regarding weatherminimums and pilot duty times; possible regulatory changes to provide for sharing and analysis ofsafety-related data and observations with some degree of impunity; possible aircraft designconsiderations to improve crash survivability; expanded application of system safety and formal riskmanagement principles to mission planning and flight operations; enhanced training for both pilotsand support personnel and operational procedures to improve coordination and situation awarenessamong the entire air ambulance crew and ground support team; and the use of various technologiesto improve pilot situation awareness and augment pilot vision in low visibility conditions.
This report will not be updated.