Trooper Stephen Bunker died flying a

mission that never should have happened, looking for a hole in the clouds that never appeared. Shortly after 11 pm on Sept. 27, 2008, Bunker's phone rang inside the Maryland State Police aircraft hangar at Andrews Air Force Base. Two young women were injured in a car crash in Waldorf, Md. They needed transport to Prince George's Hospital Center. Would Bunker accept the flight?

It was a warm and soupy autumn night. Weather reports showed thick clouds descending to 800 feet, the minimum for night flights in state police helicopters. The area 1 mile north of Prince George's Hospital was completely fogged in. Bunker hesitated.

"Well, maybe they'll change their minds," he told George Noyes, the state police flight dispatcher.

Noyes had a hunch that wouldn't happen. The call came from Charles County, where a 17-year-old EMT on the scene requested helicopter service. "When I heard it was Charles County, I knew it was gonna be Waldorf," Noyes says, "because those guys never want to drive to the hospital."

In Maryland, emergency medical service (EMS) guidelines specify that police helicopters rescue patients from accident scenes, while private air ambulance companies handle runs between hospitals and back up police. Over the radio Bunker heard that MedSTAR Transport, a private company, had just completed a job nearby.

"If they can do it, we can do it," Bunker said.

He lifted off from Andrews at 11:10 pm. Thirty-four minutes later, with both patients and two paramedics onboard, he radioed air traffic control at Ronald Reagan Washington National Airport. "Uh, yes, sir, we just ran into some heavy stuff," he said. "I don't think we're going to be able to make it all the way to the hospital."

Blinded by fog, Bunker diverted to Andrews. Three-and-a-half miles short of the runway, flying at 1900 feet, he sent Trooper 2 into a dive. The helicopter was not equipped with flight recorders, so it's unknown why he descended. But investigators believe that because he was familiar with the surrounding area, and because the sky immediately over Andrews was clear when he took off, Bunker probably thought he could duck under the clouds and land by sight.

There was nowhere to duck. Traveling at 106 mph, Bunker slammed into a tree in Walker Mill Regional Park. One patient, Jordan Wells, fell free of the aircraft and survived. Bunker and three others died.

Industry Safety ///

4 Medevac Helicopter Technologies

That Could Save Lives ///

PLUS: What You Can Do

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Medical helicopters accept the most dangerous missions in commercial aviation. They fly unplanned routes a few hundred feet above the ground, often below radar. They land on highways, mountains and farms, miles from the nearest airport weather station.

Yet Trooper 2 was typical: Most medical helicopters lack basic safety equipment mandatory on other commercial aircraft. The majority have no autopilot system or co-pilot to assist the pilot in emergencies. Medical helicopters are not required to have terrain awareness and warning systems (TAWS), night-vision goggles, flight data recorders, detailed weather reporting or ground personnel in charge of flight dispatch and in-flight tracking.

As a result of flying ill-equipped into risky conditions, medical helicopters crash at twice the rate of other air taxis and are exponentially more dangerous than commercial airliners, according to a 2009 study by Ira Blumen, medical and program director of the University of Chicago Aeromedical Network. Air ambulances have crashed 264 times between 1972 and 2008, killing 264 people. The first three months of this year kicked off with two more fatal crashes, leaving six dead (half of whom died during a military EMS simulation).

In fact, working onboard a medical helicopter is the most dangerous profession in America, Blumen found, with a higher fatality rate than that of fishermen, loggers or steelworkers.

"Most people think medical helicopters are like airliners, that they all meet the same standards," says Thomas Judge, executive director of LifeFlight of Maine. "Yet here we take injured passengers, with no choice of carrier, and subject them to this huge variation of standards that airline passengers would not accept."

Often, helicopter evacuations are not even needed to save a life. "Medics call helicopters just so a ground ambulance can stay on call," says Bryan Bledsoe, an emergency room doctor and a professor at the University of Nevada School of Medicine, who participated in an expert study of Trooper 2's crash. "Helicopters fly medically unnecessary flights every day."

The reality is that Trooper 2 did not have to crash. Since 1988, the National Transportation Safety Board (NTSB) has known that most fatal medical helicopter accidents occur when pilots unexpectedly encounter poor visibility or bad weather and become disoriented. Since then, the board has urged the Federal Aviation Administration (FAA) to require improved safety equipment on medical helicopters, to little effect. "We've been killing ourselves the same way for 30 years," says Ed MacDonald, lead pilot for PHI Air Medical, one of the nation's largest helicopter ambulance operators.

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One of the most important advances in medical helicopter safety should happen on the ground. Pilot Mark Bumstead decided it was safe to fly on an overcast night in February 2006 by walking outside and looking up, then quickly checking weather reports. He saw lightning and encountered clouds immediately after takeoff, and 3 minutes later crashed in Chesterfield, Ind. The NTSB found Bumstead's preflight weather check "inadequate."

In other crashes, pilots saw nothing but clear skies before takeoff, only to encounter storms midflight. Suddenly, they had to climb to a safe altitude, hunt for a map or consult GPS, radio for help, plan an escape from the cloud and look out the window for obstacles or a cloud break, all while watching the instruments to maintain steady flight.

Bunker's accident happened near Washington, D.C., some of the world's most highly monitored airspace. He depended on air traffic control to assist him in a dangerous situation. But when Bunker called Andrews and asked for turn-by-turn directions after becoming disoriented in fog, the controller told him she wasn't trained for that. Fifty seconds later he dropped from the radar.

The nation's aviation system was designed for high-altitude flights along planned routes. Traffic controllers help decide when it's safe to fly. They use GPS and radar to warn pilots about bad weather ahead and can guide planes to safe landings. But the system wasn't built to track small weather events at low altitudes and in remote locations, where medical helicopters sometimes fly, says John Allen, director of the FAA's Flight Standards Service. Air ambulances may land in canyons 50 miles from the nearest airport weather station, where intense storms have room to hide and air traffic controllers are powerless to help.

A 2006 NTSB report analyzing all air-ambulance crashes between January 2002 and January 2005 (air ambulances include small fixed-wing planes) found that improved flight risk assessment and dispatch and tracking systems could have prevented nearly half. "There's universal agreement that we built a really safe flight system that goes airport to airport and flies high in the sky," Judge says. "In the air medical world, we don't have that."

Every year the NTSB releases a "Most Wanted" list detailing critical changes needed to make the nation's waterways, railroads, highways and airways safer. Since 2008, mandating flight dispatch and tracking systems for medical helicopters has been on that list.

Although the FAA doesn't require medical helicopter companies to install advanced safety technology or hire trained dispatchers, some operators choose to do it anyway. Voters in Maine have agreed to spend $4 million since 2003 to install remote weather stations and GPS-based instrument approaches, improving safety for the state's LifeFlight system. It has never had a serious crash.

Air Methods, the nation's largest medical helicopter company, tracks all 313 to 330 of its aircraft from an operations control center in Englewood, Colo. Operational control specialists watch flights using weather reports overlaid on digital topographical maps. If pilots experience weather or other problems, the staff can zoom in for a 360-degree look, patch themselves into pilots' headsets and discuss alternative routes.

"Once pilots get into a flight, there's really no way for them to get ongoing updated info," says Dennis McCall, aviation compliance manager of Air Methods. "We want to look over their shoulders and help them make decisions."

When the helicopter landed in his yard, Larry Strittmatter didn't think about the cost. His wife Dana had accidentally burned her leg with boiling water. Instead of driving her to one of six hospitals within 15 miles of their house near Fort Worth, Texas, paramedics called a helicopter to fly Dana to the Parkland Hospital Burn Center in Dallas.

Shortly after Larry arrived, the doctors gave his wife a bandage, a prescription for Tylenol with codeine and a swift escort to the lobby. The hospital refused to admit her for such minor injuries, leaving the Strittmatters with a $17,000 flight bill. "The doctors said they were shocked and dismayed when they saw a helicopter landing," Strittmatter says. They had been in touch with EMTs at the scene, and after hearing Dana's injuries described had advised that she should be transported by ground ambulance.

In Arizona, 43 percent of patients transported by helicopter to hospital ERs were discharged within 24 hours, suggesting most didn't need a helicopter at all. In Maryland, the 24-hour discharge rate for patients transported by state police helicopters was 41 percent prior to 2008.

After Trooper 2 crashed, Maryland barred all but seriously injured patients from state helicopters, which it predicted would reduce the number of flights by 67.2 percent without affecting patient mortality. "If you're getting close to a 50 percent discharge rate within 24 hours, I think that's too high," says Dan Hankins, an emergency-medicine physician at the Mayo Clinic and president of the Association of Air Medical Services.

Academic studies disagree on whether medical helicopters improve EMS response times and patient survival rates. Besides severity of injury, the key factor may be flight time. Helicopters are significantly faster than ground ambulances when retrieving patients more than 45 miles away from a hospital, according to a study published in the Journal of Trauma in 2005. But closer than 45 miles, ground vehicles are just as fast--or faster--than helicopters, because helicopter crews need more time to start engines and secure equipment.

Efforts are under way to improve training for paramedics on whether or not to request helicopter transports, Bledsoe says. Meanwhile, industry insiders say that medical helicopters are overused because, in too many cases, money trumps medicine. There were 330 medical helicopters in the United States in 1997 when Congress mandated new Medicare reimbursement rates for air ambulances. Since then, the number of helicopters has nearly tripled, to 850. The industry's explosive growth is a direct result of Medicare's pay raise, says Deborah Hersman, chairman of the NTSB.

Missouri has 5.9 million people and 33 medical helicopters. Canada has 33.4 million people and 20 medical helicopters. "In many places, the [motivation] isn't medical necessity," LifeFlight of Maine's Judge says. "It's to find ways to put more people in helicopters, because otherwise we're not going to make enough money to stay in business."

On Jan. 10, 2005, Jonathan Godfrey was on duty as a flight nurse when his Eurocopter EC-135 medical helicopter, flying low and fast over Washington, D.C., entered a dark area south of the Woodrow Wilson Bridge that pilots referred to as the "black void." Twenty seconds later, he woke up on the bottom of the Potomac River, still strapped to his seat. After groping for the belt, Godfrey popped to the surface, and an hour later Trooper 2--the same helicopter that would crash near Andrews in 2008--picked him up, a broken bone poking through the arm of his flightsuit. Two others, the pilot and a flight paramedic, died.

Night-vision goggles, scheduled for installation on Godfrey's helicopter, hadn't yet been delivered. Pilots agree that goggles make a difference. In a 2008 survey by the National EMS Pilots Association, 88 percent of 382 pilots said using night-vision goggles "provides a significant safety advantage." But 40 percent said their companies didn't supply them. In the survey's comment section, one pilot says of the years he spent flying at night over the mountains of Kentucky, "We must have been out of our minds."

Of the 55 crashes reviewed in the 2006 NTSB report, night-vision goggles may have prevented 13. TAWS might have prevented another 17: In the 7 seconds before Bunker's helicopter hit trees, such a system would have detected that he was flying too low and given him three loud warnings to pull up. A September 2009 NTSB report recommended every medical helicopter also be equipped with a flight data recorder, plus either autopilot or two pilots.

After his injuries healed, Godfrey climbed into a helicopter and returned to work. He was on duty the night Trooper 2 went down nearly four years later. He heard air traffic controllers calling Bunker by radio, heard the empty static of no reply. He even drove to Walker Mill Regional Park to try to assist at the scene. Watching his friends die in machines that are supposed to save lives--twice--galvanized him. "That was a turning point for me," Godfrey says. "I wasn't going to shut up."

He began talking with the media about the industry's shoddy safety practices. He became the chairman of Vision Zero, reviving a dormant effort by the Association of Air Medical Services to raise the safety awareness of flight crews. Godfrey still pulls on a flightsuit three nights a week and tries to save another life, but he refuses to fly in any helicopter without flight dispatch, in-flight tracking, a terrain awareness and warning system and night-vision goggles. "If this industry is unsafe," he says, "no one benefits."

Since 2005, the FAA has issued guidelines encouraging medical helicopter companies to install safety technology voluntarily. In 2006, the safety board again urged the FAA to tighten regulations, and the administration refused.

Eight fatal crashes killed 29 people in 2008, the deadliest year yet. In April 2009, Allen announced the agency would write official safety rules. Since then, as this article went to press, eight more medical helicopters had crashed, leaving 12 dead.

"The problem is that in 2006 we heard that most of these things were going to be done voluntarily, and four years later we're still seeing the FAA talking about starting the rule-making process," Hersman says. "It's just too slow."

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