As the industry grows, the GAO and experts say, competition for customers has driven risky practices like helicopter shopping - where an agency calls a company for air-ambulance transport and gets turned down, but then calls another service that accepts, even if conditions are unsafe.
From 2003 to 2005, the number of helicopters used exclusively as air ambulances increased 38 percent, to 753 from 545. The number of locations they operate in increased 30 percent, to 614 from 472, according to the GAO report.
In the industry as a whole, "From a competition standpoint, there are pressures sometimes to fly," Air Methods' Stockhausen said.
Air Methods has a corporate philosophy to base all decisions to fly on aviation factors, he said. But others may face pressure, Stockhausen said. "I mean, let's face it - most of us are in it to make money, so if you're not getting the volume, then you're not covering your costs."
Even when financial issues are not a concern, "We have gotten caught up in the life-saving mission, and that allows us to maybe not make the best decisions," Stockhausen said. "It seems there are times when crews will 'push the weather"' - flying when perhaps they shouldn't.
It's an inherent tendency of air-ambulance pilots who have a "rescuer mentality," Slack said.
Last year, the air-ambulance industry in Colorado started a paging system to share information on why air- ambulance services decide to turn down a flight, aimed at preventing practices like helicopter shopping.
Air-medical transports are growing because of centralization of trauma centers and helicopter-fleet operations that negotiate contracts with medical insurers and payors to deliver patients to their facilities, Slack said. Many air-ambulance crashes occur when an air ambulance isn't necessary, according to Slack.
And the increased demand for pilots can lead to more pilots with less experience.
"Whenever you have a high growth rate, there's always a risk that safety awareness and management has not kept up," Todd said. "I think there was certainly some of that that may have given rise to the higher incident rate."
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A recent report calls for more FAA oversight and better record keeping as accidents appear to be climbing.
Within 60 days, all operators will be required to use enhanced procedures for flying in challenging weather, at night, and when landing in remote locations.
The new rules would require stricter flight rules and procedures, improved communications and training, and additional on-board safety equipment.
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