Skip Ribbon Commands
Skip to main content
Bookmark and Share this page


Remarks to the Federal Interagency Committee On EMS, Arlington, VA
Robert L. Sumwalt
Arlington, VA

Good afternoon. I want to thank you for inviting me, on behalf of the NTSB to speak to this important group.

I can’t emphasize the importance and significance of having a joint effort between federal agencies to coordinate our nation’s EMS activities.

I believe Emergency Medical Services (EMS) may be one of those services that the general public doesn’t typically think too much about until those services are needed. That said, the public does have an expectation that when the services are needed, they be provided in a timely, reliable, and safe manner.
This afternoon, I’d like to provide a short summary of 2 issues the Safety Board is concerned about regarding EMS.

First, I’ll give a brief summary of the NTSB’s activities regarding the safety of helicopter emergency medical services, or HEMS operations.

Next, I’ll transition into a brief discussion of a motorcoach accident near Mexican Hat, Utah that the Safety Board recently deliberated on.

This accident occurred in Mexican Hat, Utah, in January 2008 and it highlights key issues that are related to EMS services in rural communities.
Specifically, this accident illustrates how some rural communities rely on helicopters to provide transport for patients in rural areas. In this case, weather prevented helicopter transport.

The accident also noted that due to lack of wireless communications capability, there was a delay in accident notification and response.

NTSB does not have regulatory authority. When we uncover a deficiency, we cannot enact a law or regulation to “fix’ the problem. We can only issue a safety recommendation to the appropriate organization and then see what happens. The big stick is that we track these recommendations and DOT agencies are required to report to Congress those recommendations that they haven’t implemented.
Overall, 82 percent of our 13,000 recommendations have been accepted.

So, let’s start with HEMS issues.

The HEMS industry provides an extremely important service by transporting seriously ill patients and donor organs to emergency care facilities. Indeed, they are credited with saving countless lives, over 400,000 people each year.

That said, the recent accident record is alarming and it is unacceptable. In the last 6 years, there have been 84 HEMS accidents, resulting in 77 fatalities. Last year was the most deadly year on record for medical helicopters. 

The Safety Board has a long-standing interest in EMS aviation. In 1988, the Board conducted a safety study of commercial EMS helicopter operations. Dr. Bob Dodd was responsible for this study and I would like to thank him for being with me here today.

This safety study evaluated 59 EMS helicopter accidents and resulted in the Safety Board issuing 19 safety recommendations.

Prompted by a rise in HEMS accidents, in January 2006, the Safety Board adopted a Special Investigation Report of EMS Operations.  This investigation looked at 55 accidents that included 14 airplanes and 41 helicopters. As a result of this report, the Board issued 4 safety recommendations to the Federal Aviation Administration (FAA) to improve the safety of these operations.

It was determined that 29 of the 55 reviewed accidents could have been prevented if corrective actions from the report had been implemented.

The Board issued 4 safety recommendations to the FAA:

  • Require all EMS flights – even those flights without patients onboard  - to be conducted in accordance with FAR Part 135 on-demand charter regulations
  • Develop and implement flight risk evaluation programs
  • Require formalized dispatch and flight-following procedures including up-to-date weather information
  • Install Terrain Awareness and Warning Systems (TAWS) on aircraft.

These recommendations were added to the Safety Board’s Most Wanted List of Transportation Safety Improvements in October 2008. The decision to place these recommendations on the Most Wanted List was prompted by the FAA’s lack of timely action on the recommendations, and the appalling number of HEMS accidents.
Currently, 3 of the 4 safety recommendations are classified as “Open—Unacceptable Response.”

The Safety Board is concerned that these types of accidents will continue if a concerted effort is not made to improve the safety of emergency medical flights. 

The FAA and industry have been holding out for voluntary compliance.

In February of this year, the Safety Board held a 4-day public hearing public on HEMS, making it one of the longest NTSB public hearings on record and I had the honor to serve as chairman of the board of inquiry.  

The hearing took a comprehensive look at the HEMS industry. One objective was to gain a better understanding of why this industry has grown significantly in recent years and to explore if the increase in accidents was related to increasing competitive pressure to complete flights. We examined flight operations procedures including flight planning, weather minimums, and preflight risk assessment. We discussed safety enhancing technology such as TAWS and Night Vision Imaging Systems. Training, including use of flight simulators, was discussed, and we probed the corporate and government oversight of HEMS operations. 

Possible courses of action resulting from this hearing are numerous, including an updated safety study on EMS operations and additional safety recommendations. NTSB staff is currently examining the information from the public hearing which totals well over 3,000 pages and our staff is planning to bring safety recommendations to the Board.

Whatever we do, our motivation is simple – find innovative ways to improve Helicopter EMS safety.

After our public hearing, Congress gained interest in this issue and held its own hearing. To the FAA’s credit, in Congressional testimony in April, FAA announced their intentions to initiate rulemaking.  They conceded that voluntary compliance was not working and rulemaking will “level the playing field.”

My next discussion will cover a motorcoach accident that occurred in January of last year on a rural highway located near Mexican Hat, Utah.

It may appear that I am moving away from Helicopter EMS concerns to highway safety but I assure you that this accident shows what can happen when HEMS are not available.

During the accident, a motorcoach departed the roadway and overturned. The roof separated from the body of the vehicle during the rollover and 50 of the 53 passengers were ejected.

Looking at the initial emergency notification and response, the accident occurred at 8:02 pm and the first phone call to 911 dispatch occurred at 8:04 pm. Unfortunately, this initial phone call was lost. And the 911 dispatcher mistakenly thought this dropped call concerned another motorcoach accident in the same area that involved a minor fender-bender with another vehicle and never followed up. The second call to 911 dispatch was not received until 8:34 pm. This call was made by a passerby who drove on to Mexican Hat and placed the call from a service station. Due to the delay in notification, the initial first responders did not arrive to the accident site until 8:56pm. Fifty-four minutes after the accident occurred.

During our investigation, we found from our research that 40 percent of all calls to 911 call centers are made from cellular telephones. And as we all know, everyone these days has a cell phone. Eighty percent of Americans are subscribers to wireless services. 

These statistics clearly show the need for reliable wireless communication capabilities especially in these rural locations where this accident occurred.
Summarizing our concerns with the emergency notification of this accident, we have determined that it is the responsibility of FICEMS to coordinate, at a Federal level, State EMS programs. FICEMS should also develop a plan for wireless communication coverage along high-risk rural roads and along rural roads with substantial large bus traffic.

The emergency response experienced during this accident was another component of concern during our investigation. Medical support used during this accident came from all over the area and across several states. As you can see, this accident caused 9 fatalities, 44 injuries, and treatment was given at 12 different hospitals and medical center including a clinic.

It is also important to note that EMS helicopters were called to assist however they were unable to fly to the accident location due to weather. The inability to use HEMS during this accident was a major problem for transporting the injured. They were not able to depend on the fast response of these helicopters.

Looking at the accident location, the injured passengers were initially transported to three medical service sites. None of these locations had trauma designations and some of the passengers were later transported even further from these sites to better equipped facilities.

Many of the injured passengers were taken even further to hospital facilities 340 to 360 miles from the accident site including a children’s hospital in Salt Lake City. 

Returning to the initial emergency response, the first ambulance did not arrive to the scene until one hour after the accident occurred and the last ambulance did not arrive until four hours after. Medical assistance was supplied by four states and no medevac helicopter services were available causing an extended response time due to the travel distance.

The emergency plan and procedures were a problem in this accident. They continue to be a concern for the Board and we’ll continue to look at issues including poor cellular telephone communication, medevac response limitations, and the lack of a mass casualty incident plan for transportation-related events for these rural location.

It is important to have contingency plans for situations where medevac services cannot respond. This is why NTSB is asking FICEMS develop guidelines for EMS response and provide those guidelines to the States.

Again, thank you for allowing me to speak to your committee today. I look forward to working with you and please let us know if there is anything the NTSB can assist you with. I would be happy to answer questions you may at this time.