Throughout 2008, the EMS helicopter crashes mounted, and the industry stewed. Given the legislative dichotomy surrounding air-medical issues--states control the medical, the feds govern the air--and the disparate interests of the fast-growing numbers of providers filling the HEMS market, doing anything about it was going to be difficult. Even identifying the measures most likely to improve safety stoked disagreement and factionalization. Did the best solution lie in technologies like night-vision goggles or terrain awareness warning systems (TAWS)? Would using a flight risk-evaluation checklist or safety management systems help? Was better infrastructure for low-altitude flights or limiting aircraft numbers the answer? It often depended on whom you asked and what their interests were.

By early 2009, though, that lack of consensus was no longer inhibiting action. A flurry of activity in the federal executive and legislative branches aimed to change the rules of the airborne-EMS game, and a major effort from within the industry itself sought to clarify matters of safety and clinical capability.

As this is written at the end of April, it's not known which of these efforts might come to fruition, mutate into something else or die unripened on the vine. Nor is it known for sure, should any or all of them succeed, what the impact to the bottom-crash-line or any unintended consequences might be.

But know this: If the HEMS crash and fatality rate doesn't decline in the near future, it won't be from a lack of trying.

NTSB VS. FAA

The National Transportation Safety Board (NTSB) started agitating for new rules to enhance HEMS safety in 2006. Following an investigation of 55 accidents over three years, it urged the FAA to institute four new safety requirements: operations under Part 135 of the Federal Aviation Regulations anytime a medical crew is on board; use of flight risk evaluation programs; use of formalized dispatch procedures with weather and risk-assessment assistance; and use of TAWS. Rather than mandating these, though, the FAA sought voluntary compliance with them by operators.

Three years later, with crashes spiking again, the NTSB was back on the case, hosting four days of hearings in February to suss out the industry's current profile and potential solutions to its problems.