Correction to This Article
A chart with an article on medical helicopters, and a reference in the story to the same data, cited occupational fatalities for airline pilots. The figure of 80.1 deaths per 100,000 people over the past 10 years is for all professional aircraft pilots, not just those working for airlines.
The Deadly Cost of Swooping In to Save a Life

By Gilbert M. Gaul and Mary Pat Flaherty
Washington Post Staff Writers
Friday, August 21, 2009

SANTA ROSA BEACH, Fla. Shortly after midnight on a storm-swept October night in 2004, Tom Palcic, a medical helicopter pilot, started across Choctawatchee Bay to pick up a hospital patient and transport him to a facility 60 miles away.

Such flights are common in the highly competitive multibillion-dollar air-medical business. Although the public profile of medical helicopters has them swooping to crash scenes at the edge of highways, most flights, like Palcic's, involve shuttling patients between hospitals.

The director of the helicopter program for which Palcic flew called these lucrative patients "golden trout" and pushed pilots to reel in as many as possible. When pilots balked at flying in bad weather, he called them sissies and second-guessed them, records and interviews show.

Palcic, 63, was just two minutes into the flight of AIRHeart-1 when his crew radioed a dispatcher that he was turning back because of the thunder and lightning.

Moments later, Palcic's helicopter banked in clouds and plunged 700 feet into shallow waters, killing him, a flight nurse and a paramedic. A woman who lived nearby recalled that the vibration shook candlesticks out of their holders.

For the medical helicopter industry, it was the fourth fatal crash that year -- part of a legacy that has claimed the lives of 211 crew members and 27 patients since 1980 and injured many others, The Washington Post has found.

The number of fatal flights has risen sharply, closely tracking the rapid growth of what is now a $2.5 billion industry. Nearly half of all deaths have occurred in the past decade. In 2008, the deadliest year ever, 23 crew members and five patients were killed.

Some calamities were the result of pilot errors. But many were predictable, pilots and safety experts say, and could have been prevented with stronger oversight and better technology.

"We've been killing ourselves the same way for 20 years," said veteran pilot Ed MacDonald. "There's not a whole lot new about these crashes."

What began almost four decades ago as a way to save lives is now one of the most dangerous jobs in America -- deadlier than logging, mining or police work -- with 113 deaths for every 100,000 employees, The Post found. Only working on a fishing boat is riskier. The rate for airline pilots is 80.1.

In the 37 years helicopters have been used to transport patients, pilots and crews have died in an almost unfathomable array of crashes. In the past two years alone, medical helicopters have dropped into pitch-black oceans, plummeted to the ground after losing rotor blades, smacked into mountains and collided in clear blue desert skies.

Yet as crashes and deaths have mounted, top executives at the Federal Aviation Administration and its parent agency, the U.S. Transportation Department, have acted as partners with the industry, issuing reams of voluntary safety advisories with little follow-up. The FAA has sent poorly trained inspectors to monitor operators and used fines and penalties as only a last resort.

"I'd rather use a carrot than a hammer," said John M. Allen, the FAA's director of flight safety standards. "It's not like we do nothing and then smack them with a rule."

Allen said the agency has to balance business and safety. "Even one crash is too many," he said. "But there's a fine line on how far does government go to impact business."

Private, for-profit companies dominate the industry, with about 830 medical helicopters vying for patients. The number of aircraft has doubled every decade since 1980, leaving some firms with fleets as large as those of US Airways or JetBlue. Yet medical helicopters are permitted to operate without basic safety features that commercial flights must carry, such as black box recorders, collision-avoidance systems and radar altimeters.

Unlike an airliner, a medical helicopter does not fly a direct route from one airport to another, seamlessly tracked by radar. Most flights are at low altitude. There might or might not be an established landing zone.

Because of their low flight paths, helicopters are especially vulnerable to rapid changes in weather. Most flights are made under visual flight rules, with the pilot using his eyes to pick through clouds and around obstacles, and often are to out-of-the-way accident scenes. Unlike commercial airline trips, only a fraction of helicopter flights are conducted under instrument flight rules, which make it easier to travel in inclement weather.

More than half of fatal crashes occur at night, but only one-third of medical helicopter pilots are equipped with night-vision goggles to help them avoid power lines, towers and other obstructions.

Industry officials are well aware of the risks, noting in public statements that medical flights are inherently dangerous. They emphasize the thousands of patients they safely transport each year and the many lives that have been saved. They also say helicopters are critical in rural areas.

Although the industry has not advocated for a specific federal safety requirement, companies have made individual improvements and supported voluntary guidelines, said Christopher Eastlee, a spokesman for the Air Medical Operators Association.

The accidents last year "lend themselves to safety concern in the industry, but I don't think that translates into a safety problem," said Eastlee, whose group represents more than 90 percent of the industry, which is dominated by five private companies and dozens of smaller programs.

Industry officials have been slow to adopt safety technologies until recently and urged more studies, citing the expense and readiness of the equipment. Operators also have successfully sued state regulators who tried to restrict the number of helicopters in their areas based on a community's medical need.

In effect, the FAA and Transportation Department treat the companies the same as low-fare carriers to Disney World, contending that a deregulated, unfettered market will drive down costs through competition.

The model hasn't worked.

Costs keep increasing, with a one-way trip running as high as $20,000. Medicare alone spends $220 million yearly to ferry patients -- 20 times higher than a decade ago, adjusted for inflation. Air Methods, the largest firm, has revenues of $500 million.

The unchecked growth has saturated some regions.

In Kentucky, "all of a sudden, the skies were almost black with helicopters," recalled Brian K. Bishop, a former regulator.

With a population of 4.2 million, Kentucky has 26 medical helicopters -- more than many nations. Canada, which is about nine times as large with a population of 33 million, has 20. It has never suffered a fatal crash.

'Like Flying Billboards'

The idea that helicopters can be used to swiftly transport critically injured patients to trauma centers and other hospitals grew from the experience of surgeons and pilots during the Vietnam War.

"What we learned was if we got to them quickly enough and got them to the right people, we could save lives," said MacDonald, a Dustoff pilot in Vietnam who flies a medical helicopter in New Mexico. "When we came back, we took a look around and said, why aren't hospitals doing that here?"

It didn't take long for hospitals and private operators to catch on. In 1980, there were about 40 medical helicopters in the United States. In 1990, there were about 225. Today, there are more than 800. Texas alone has 67. Arizona has 54. Pennsylvania: 45.

Virginia has 24; Maryland, 17; and the District, 5.

Operators say the extraordinary rate of growth reflects "pent-up demand" for the services, especially in rural areas without trauma centers. But as with many expensive technologies, the increase appears to have as much to do with making money as with medicine. Complaints about overuse are common, with patients walking off helicopters with sprained ankles or being discharged within a few hours from emergency departments.

"A patient flown in by helicopter can mean thousands of dollars in downstream revenue" once the patient is admitted to a hospital, said Paul A. Taheri, a doctor who co-wrote a 2003 study on the subject. "That fact is not lost on hospital administrators."

A helicopter also helps to burnish the image of a hospital as a lifesaving facility.

"They're like flying billboards," says Thomas P. Judge, executive director of LifeFlight of Maine, a statewide program with two helicopters. "It's the equivalent of a medical centerfold. It's sexy advertising."

In the late 1990s, Congress prodded Medicare, the nation's largest insurer, to change its formula for paying for helicopter transports. In 2002, Medicare boosted its reimbursement rates and started paying a 50 percent premium for rural flights. The spigot of new money expanded the market for private operators, who responded by opening scores of free-standing bases miles from hospitals. Medicare payments soared, increasing 434 percent in seven years, to $220 million last year.

Today, programs charge thousands of dollars for a flight, billing records show, and compete ferociously in heavily populated cities and suburbs. To shore up support among local fire, emergency medical service and hospital workers -- who often control which helicopter team is requested for a patient -- marketing teams have offered NASCAR tickets and hosted riverboat cruises, company e-mails and interviews show.

Some helicopter crews pass out T-shirts and bottle coolers at accident scenes. "I like to look out at a scene and see a Wings cap out there," said Steve Lewis, a base manager for Wings Air Rescue in Johnson City, Tenn.

To fend off competitors, companies add more helicopters than are needed.

"If I had no competition in the United States, I could probably reduce the number of bases by 30 or 40 . . . and still have adequate service," Air Methods chief Aaron Todd told investment analysts in November.

Medicare pays ground ambulances based on the level of care they provide; the more sophisticated the care, the higher the reimbursement. But when it comes to paying medical helicopters, the government insurer assumes all helicopters and crews are alike.

"It's crazy," LifeFlight's Judge said. "It doesn't matter if you are flying a refurbished helicopter with an inexperienced crew or a helicopter that costs millions of dollars and is equivalent to a flying ICU. They pay the same."

Private investors have also poured millions of dollars into the medical helicopter industry, helping to fuel its rapid growth. In 2004, Brockway Moran & Partners, a billion-dollar private equity firm in Boca Raton, Fla., added Air Evac Lifeteam to its portfolio. Two years later, it acquired Med-Trans, another large operator. It picked up a third last month. Several other firms also jumped in.

The influx of private money transformed the industry, said Christine M. Zalar, a consultant. "A lot of money was going into this thing, and it started to feed on itself," Zalar said. "I think a lot of business people were sitting in a room saying, 'Hey, look at all of the places we can put these things and make a lot of money.' " Companies operate under a simple formula: The more they lift off, the more they earn. "It's pretty easy math," Zalar said. "If you aren't flying, you aren't paying."

Fishing for 'Golden Trout'

Keeping up the numbers was on the minds of pilots and managers during the 2004 AIRHeart-1 crash. Investigative records obtained by The Post depict a program divided by pressures to lift off, even in bad weather.

AIRHeart-1 was part of the Sacred Heart Health System, a $600 million hospital network based in Pensacola, Fla. Sacred Heart provided the nurses, billed the patients and stationed Randy Layman as program coordinator in Santa Rosa Beach. Metro Aviation, a private company in Shreveport, La., received a fee to provide the helicopters and pilots.

After the crash, lead pilot Wayne Weir told investigators that pilots complained that Layman pressured them to fly. If pilots refused flights, Weir said, Layman "would check the weather. It would be obvious that he was looking over the pilots' shoulder."

Weir added: "He says every patient is a golden trout. We need to go get those trout."

James E. Light, another pilot, told investigators that Layman "joked about me being a sissy" for turning down flights in bad weather. "He shouldn't kid about that," Light said. "This could affect pilot decision making in an insidious way, on an unconscious level; I think pressure to fly describes it."

Still another pilot, Thomas Dunn, said: "There is a veiled hostility between the pilots and the program director. That was true prior to the accident. He overinvolves himself in stuff he's not supposed to maintenance- and flight-wise. He creates a very uncomfortable situation and working environment."

Layman said it was "disturbing and disappointing" that pilots accused him of interfering and name-calling. "I don't think there is any evidence that there was pressure placed on the pilot," he told a Post reporter.

He said he was terminated by Sacred Heart a few months after the crash. He declined to provide details, saying it was a "delicate question. By mutual agreement I received a very heavy severance from them [Sacred Heart], and we moved on." Sacred Heart officials declined to discuss his comments.

Layman said the term "golden trout" was his way of emphasizing to pilots the importance of being ready to take missions.

Asked whether he was expected to meet flight quotas, Layman said, "You don't have to be a math wizard to understand that missions equal revenue, and revenue equals survivability in the air business."

A Hands-Off Approach

In July 2008, Federal Aviation Administration officials hurriedly arranged a meeting with industry leaders to discuss a spike in fatal medical helicopter crashes. Only days before, two medical helicopters had collided in daylight over Flagstaff, Ariz., killing five crew members and two patients. A spate of earlier crashes had claimed 17 lives.

But instead of ordering changes, regulators asked companies to "refocus" on safety, according to a summary of the meeting. Stricter regulation was quickly ruled out.

That hands-off approach is typical of the FAA's history of deferring to the industry on safety matters, The Post found.

During the past five years, the agency has issued civil penalties totaling less than $90,000 to the medical helicopter companies that account for most of industry. There were no suspensions or license revocations. Fines arise only in "the more egregious cases," FAA spokeswoman Diane Spitaliere wrote in an e-mail response to Post questions. "Our goal is to achieve compliance, rather than hit the operator with a fine."

The FAA does not require companies to report their total flights and flight hours, which other federal agencies said is needed for effective monitoring.

The FAA also has been slow to push for new safety systems -- including night-vision goggles and terrain-awareness and -warning systems -- saying they need more study and could drive some operators out of business. "We have to be careful," Allen said. "We might be doing a disservice to the public."

Gary Sizemore, a medical helicopter pilot who was based in Perry, Fla., said goggles would improve safety. "I'm hoping we will get them before long. Because a lot of the areas we fly are dark, it would be a great help."

One reason for the lag is a shortage of FAA inspectors to certify the use of goggles for thousands of waiting pilots and crew members. The FAA has nine inspectors for that task. In June, an FAA official said the agency doesn't have enough goggles for its inspectors. Before a roomful of industry representatives, he suggested the agency could rent them from operators when its inspectors arrive for "check" rides that test pilot skills.

In an interview, Allen quickly ruled out that idea. "I don't want them renting from industry," he said. "That wouldn't be good."

Eastlee, the air operators spokesman, said his members hope to be equipped with night-vision goggles by the end of next year. "There's no way to really enforce that," he said. "But that's what the commitments are."

Pilots also complain that FAA inspectors lack experience in helicopters -- an accusation FAA managers do not dispute. An inspector checking pilots in Nebraska last year had flown in a medical helicopter only three times.

The FAA has about 280 inspectors "qualified" in helicopters, but they are generalists who also handle airplane and other duties. Recently, the agency started a program to hire former helicopter pilots to beef up its inspections. As of last month, it had hired six. Allen said it will take 18 months before they "got traction."

Inspection reports obtained by The Post depict inspectors bogged down in check lists and minutiae, including the color and neatness of files. In Maine, an FAA inspector cited an operator because its duct tape was too old. "We didn't know duct tape had a shelf life," LifeFlight's Judge said.

If FAA inspectors find a problem, "we empower them [the operators] to fix it themselves basically," said Jon Prater, an FAA regulator who explained the process at a National Transportation Safety Board hearing. "Predominantly everybody does want to follow the rules."

Allen said that regulators and the industry work closely to sort through safety questions but that the industry pushes back over cost and control. He cited flight recorders and attempts by the FAA to regulate pilot flight hours and scheduling.

When the FAA looked at pilot fatigue, it proved to be "very, very sensitive with industry, and we really didn't get anywhere to making substantive changes," Allen said. And when the agency "starts asking for data from the industry, they get very nervous."

"I'm not aware of those issues," Eastlee said, "but if that is his perception I'd like to work with him on addressing it."

Summits and More Summits

When crashes first spiked in the mid-1980s, industry officials and regulators held a summit to discuss what they could do to improve safety -- the first of many such meetings held over the past two decades.

Some victims' families say that is the standard government-industry response: to hold another safety summit whenever the glare of unfavorable publicity rains down.

Last year, amid a record number of fatal crashes, two summits were held: one in Washington and one in Dallas. They followed summits in 2000 and 2004, as well as a 2004 government task force.

Allen said the FAA issued "numerous" voluntary safety advisories in 2005 as a result of the task force's work. "The first thing we do is awareness," he said. "The safety equation is not unilateral. It's industry and us."

In February, Allen told the NTSB that the FAA's safety advisories resulted in a "drastic reduction" in fatal crashes between 2004 and 2007. "The numbers prove it," Allen testified.

In fact, the numbers show that fatal crashes jumped sharply in 2004 and 2005. And after dipping in 2006-07, they spiked again last year, with seven.

Questioned about his testimony, Allen said in an interview: "I should probably not have not said drastic. Drastic was an overstatement."

The cycle of crashes followed by meetings and studies is not new, said Gerald L. Dillingham, a Government Accountability Office investigator and author of a 2007 report critical of medical helicopter safety reporting. "The pattern we are seeing is a pattern we have seen before," Dillingham said. "As time passed and attention waned," interest in the safety issue faded.

In 1987, after a cluster of fatal crashes, the FAA conducted a 60-day review of medical helicopter operations, followed by more voluntary advisories. A year later, the NTSB issued a 130-page report that found a "significant rise in the number of accidents."

Problems identified by the NTSB in 1988 continue to affect the industry: poor communications, competitive pressures to accept risky missions, pilot fatigue and a lack of equipment to help pilots flying in dark, unfamiliar settings.

FAA officials said they work closely with their NTSB counterparts. However, as a separate agency, the FAA is not obligated to accept the NTSB's findings -- and sometimes doesn't.

In 2006, the NTSB issued another long report on medical helicopter crashes. It recommended that the FAA require operators to add terrain- awareness and -warning systems, supply their crews with night-vision goggles and implement formal programs for pilots to evaluate risks before flying in bad weather. FAA officials balked, saying several recommendations were impractical or costly or required more study.

Last year, the NTSB upped the ante, adding four of the recommendations the FAA had not implemented to its Most Wanted List -- a public catalog of the NTSB's most pressing safety concerns.

There is a natural tension between the FAA and the NTSB, said James E. Hall, a former NTSB board member. "The NTSB is the investigator. The FAA is the regulator. The FAA isn't going to accept everything the NTSB says, nor should it."

At the same time, Hall said, "Many people in the bureaucracy of the FAA still feel their mission is as much to promote aviation as to provide for safety." As a result, the agency is slow to push new rules. "It's tombstone technology," Hall said. "You have to have enough deaths to justify a rule change."

Allen said: "The FAA never shies away from issuing rules. However, our main focus is on getting immediate results when there is a safety issue -- by whatever means is fastest."

Patricia Schroder of Pittsburgh, whose brother, flight nurse John Stumpff, died in a December 2007 crash in snow and mist near Whittier, Alaska, said the FAA should have had stricter rules in place requiring night-vision goggles and other equipment. "It's one thing to be completely oblivious to certain weaknesses within a system," she said. "But how tragic is it when you have recommendations from the NTSB several years earlier [2006] and no apparent action? It's extremely frustrating, and it makes me angry."

Allen said that before the FAA could write a regulation requiring helicopters to use night-vision goggles or terrain-warning systems, it would need industry buy-in. "We have to learn what would be acceptable," he said. "We're studying the heck out of these things."

'Helicopter Shopping'

Under federal law, the FAA and Transportation Department have responsibility for fares, routes and safety. That includes the type of helicopter, avionics equipment, pilot training, routes and acceptable weather conditions for flight. State health officials are responsible for licensing the nurses and paramedics and approving the medical equipment used on the helicopters.

Eastlee and his trade group contend that the two-pronged regulatory model works well and has resulted in numerous "safety enhancements."

But a growing number of state regulators and some hospital-based helicopter programs counter that the approach is confusing and that federal law prevents them from making medical helicopters even safer. They point to a practice known as "helicopter shopping" as an example.

Helicopter shopping refers to hospitals or EMS dispatchers calling companies until they find one willing to take the flight. The practice is considered dangerous when dispatchers don't tell the pilots that other operators have rejected the same flight or aborted because of weather.

A July 2004 incident spotlighted the practice, when a medical helicopter in South Carolina crashed into trees shortly after liftoff from an accident scene, killing the pilot, flight nurse, paramedic and patient. The pilot hadn't been told that three pilots had rejected the flight, including one who turned back because of fog.

But helicopter shopping continued, and investigators have singled it out as a contributing factor in fatal crashes in recent years in Utah and several other states.

Chris Waters's 27-year-old wife, Stephanie, was a paramedic on a helicopter operated by PHI Air Medical that crashed in a dark forest in June 2008 near Huntsville, Tex. Earlier, another helicopter had aborted a flight while trying to pick up the same patient.

PHI said its pilot became disoriented because of the dark terrain. The pilot was not wearing night-vision goggles, and company said it has since installed them throughout its air-medical fleet.

The night of the crash, Waters called his wife's cellphone and was surprised when she answered during her flight.

"It was strange," Waters said, "she usually didn't pick up when she was on a flight. I got one last chance to say I love you. In my case, it was 'Good night, see you tomorrow,' and she's gone forever."

FAA officials decry helicopter shopping, but they add that it is not their responsibility. "That's an economic issue. We cannot do anything specific," Allen said. "It's not something we can get into a regulation."

In April 2006, the agency wrote to state EMS directors, asking for their help in reducing helicopter shopping. The FAA suggested that state regulators send a memo and establish a "standard for EMS dispatch in your state which prohibits" the practice.

Some state EMS directors were taken aback. "If it's an economic issue, which is what they appear to be saying, we can't touch it," because of recent court decisions, said R. Shawn Rogers, the EMS director for Oklahoma, where the number of helicopters soared from four to 34 in eight years.

The legal battles have turned on the federal Airline Deregulation Act of 1978, which was meant to spur competition among major airlines. A provision of the act prohibits states from interfering with airline prices, routes or services. The provision has helped medical helicopter operators pry open markets and boost business even as Rogers and others decry its impact on safety.

State regulators contend that health planning and emergency care have traditionally been state responsibilities. They say they should be able to regulate medical helicopters the same way they do ground ambulances. They want to require operators to obtain Certificates of Need to justify why an expensive service should be added in a region. They also seek to require them to use specified safety equipment and be available round-the-clock.

But providers and federal regulators argue that the deregulation act gives the FAA exclusive power over commercial aviation, including medical helicopters. They reject calls for an increased state role, contending the division of powers between the states and federal officials works well.

"We are concerned that fifty separate State regimes addressing the economic regulation of air ambulances could unnecessarily complicate the industry and hinder interstate operations," Christa Fornarotto of Transportation, the parent department of the FAA and NTSB, testified to Congress in April.

That means Oklahoma "can't require air conditioning" on helicopters even though it reached 105 degrees this summer or "enforce radio frequency coordination," Rogers said. "Any rule the air ambulance industry objects to is subject to lawsuit."

Voluntary Compliance

The FAA's voluntary approach to oversight relies in large part on trust.

In 2005, the agency issued a series of "Best Practices" to operators, recommending training, risk assessment for pilots and equipment such as flight recorders and collision-avoidance systems.

Agency officials made clear that they were not issuing mandates. One FAA official told operators that they should continue to police themselves, auditing their safety programs.

Records show that the agency didn't track its 2005 recommendations to see whether operators were voluntarily complying until this year, and only then when it faced increased scrutiny over the dramatic increase in fatal crashes.

In January, agency officials ordered their lead inspectors to go back and survey medical helicopter companies to gauge compliance. The memo was issued three weeks before FAA officials were scheduled to testify at an NTSB public hearing in Washington on the crashes. Inspectors were required to return their forms two days before that session.

In an interview, Allen acknowledged that the impending hearing prompted the survey, adding that the FAA had no system for tracking compliance in the interim. "Not formally," he said, "no."

The inspectors checked paperwork at their offices rather than visiting helicopter companies. Nevertheless, at the NTSB hearing, FAA officials enthusiastically pointed to the surveys as evidence that voluntary initiatives were working.

FAA officials at the hearing said voluntary measures were just as effective as rules, which take years to approve.

Shortly after the hearing, FAA officials abruptly reversed their position. Allen announced in April that the FAA was preparing to propose new rules requiring many of the same technologies singled out by the NTSB four years earlier.

"We recognize that relying on voluntary compliance alone is not enough to ensure safe flight operations," said Allen, adding that the rules could take several years to draft.

In the interview with Post reporters, Allen said the shift was not a policy reversal. "Nothing really changed," he said. "We were working up to it. Our voluntary initiatives were a precursor to rulemaking so we know what works well."

For Stacey Friedman of El Dorado Hills, Calif., the FAA's shift is bittersweet. Her sister, flight nurse Erin Reed, was killed in 2005 when her helicopter plunged into Puget Sound.

"The sad thing is, it took all of this time and all of these crew members who died for them to announce this change," she said. "It felt a little like a triumph, I guess, but it also felt like a stab in the heart in the sense that they were years too late."

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