Air ambulances often fly into rough terrain in bad weather at night to try to save lives. Those conditions, combined with heavy competition, can contribute to air ambulance helicopter accidents.

Air-ambulance operators, including Air Methods based at Centennial Airport here, have been turning to better technology to try to increase safety. Air Methods is the largest air-ambulance operator in the country and has operations in Colorado known as Flight For Life and AirLife.

But company officials know the tendency of pilots to fly in unsafe conditions is still a leading cause of accidents.

"We've been struggling with these issues for as long as I've been in this business," said Ed Stockhausen, Air Methods' director of safety. "The reasons we were having accidents 25 years ago are still the same reasons we're having accidents today."

After nearly two years without an accident for Air Methods, three people died in December in the crash of a helicopter based in Victorville, Calif., and operated by Air Methods subsidiary LifeNet Inc.

A Government Accountability Office report released to the public last month drew attention to an air-ambulance industry accident rate higher than historical norms and called for better oversight by the Federal Aviation Administration and more data on the industry's record.

The number of accidents involving air ambulances tripled from six in 1998 to 18 in 2003. It declined to 12 in 2004 and 11 in 2005 -- still above 1980s levels. The drop may reflect increased industry safety efforts, the report said.

What is unclear is the rate of accidents per flight operation. There is no industry-wide flight-hour data, "making it difficult to determine whether the industry has become more or less safe," the report said.

A National Transportation Safety Board special investigation in 2006 recommended that the FAA require air ambulance operators to comply with stricter regulations to improve safety. In an air medical mission, there is a higher risk than other types of flights because of time pressure, operations at night and in bad weather and at impromptu landing sites. "The acceptance of that risk to bring these life-saving services to the communities across the country is absolutely justified," said Air Methods chief executive Aaron Todd.

But the FAA's oversight approach is not geared toward air-ambulance operators, and uses the same set of regulations as it uses for air-taxi services, according to the GAO report.

Air Methods and others in the industry are in the process of putting in new safety systems that follow recommendations from the FAA.

The company is also gradually putting in place new technologies including night-vision goggles, although one of the problems is getting the goggles, Stockhausen said. "There's only a few companies that make them and the war effort has taken up a lot of that capability," he said.

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 that bases 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," said Mike Slack, an Austin, Texas, attorney specializing in aviation law.

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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