The National Transportation Safety Board (NTSB) is a uniquely independent federal agency responsible for investigating airplane accidents, determining the probable cause of accidents, and making recommendations to help protect against future accidents. The NTSB can neither promulgate nor enforce any air safety regulations. It simply analyzes accidents and recommends ways to prevent similar accidents in the future.

The NTSB recently issued nineteen recommendations to toughen the oversight of Helicopter Emergency Medical Services (HEMS). The NTSB's recommendations address a variety of safety issues.

The NTSB recommends that HEMS operators (1) develop criteria for scenario-based HEMS pilot training, including training related to unique HEMS hazards and simulator training; (2) implement a safety management system program for HEMS operations; (3) install flight data recording devices and establish a structured flight data monitoring program to identify deviations from established norms and procedures; (4) install and train pilots on night vision systems; and (5) equip helicopters with autopilots. The NTSB recommends that the Federal Aviation Administration (FAA) make the foregoing a requirement for HEMS operators. In addition, the NTSB recommends that the FAA (1) require annual reporting of total hours flown, revenue flight hours flown, revenue miles flown, patient transports completed and number of departures by HEMS operators; (2) permit the use of the Aviation Digital Data Service Weather Tool as an official weather source; and (3) evaluate whether a low-altitude airspace infrastructure can viably accommodate HEMS operations.

The NTSB recommends that CMS reevaluate its HEMS reimbursement rate structure to determine if reimbursement rates should differ according to the level of HEMS transport safety provided. The NTSB also requests its staff to draft additional recommendations regarding safety audit standards that CMS should incorporate into its conditions of participation. Finally, the NTSB recommends that national guidelines be developed for the use and availability of HEMS helicopters.

In a separate August 7, 2009, letter to the FAA, the NTSB recommended that the FAA address pilot fatigue issues, which also are an area of concern in HEMS operations. The letter requested that the FAA (1) identify pilots at high risk for obstructive sleep apnea and address obstructive sleep apnea issues in the pilot medical examination process; and (2) conduct research examining how pilot fatigue is affected by the unique characteristics of short-haul operations and identify methods for reducing those effects including research into the interactive effects of shift-timing, consecutive days of work, number of legs flown and the availability of rest breaks and issue interim guidance, as information from the study becomes available. Fatigue has been listed on the NTSB's "Most Wanted" list of transportation safety improvements in aviation since 1990.

While these safety recommendations have not yet been implemented by the FAA as operating requirements for HEMS operators, the recommendations warrant strong consideration by HEMS operators.