Paramedic's Family Out of Court in Skylife HEMS Crash

The NTSB hasn't yet issued its report on the fatal Skylife air ambulance crash in December 2015. But a Fresno judge has ruled that regardless of the cause, the family of one of the paramedics on board will not be allowed to sue either the operator of the helicopter (Rogers Helicopter) or the helicopter's owner,   (American Airborne), regardless of whether they were negligent in the helicopter's operation or maintenance.

As it turns out, both entities were partners with the paramedic's employer, Skylife .  An employee cannot sue his employer for a work related injury or death.  Nor can he sue the employor's partner.

Such claims are barred by the Workers' Compensation laws.


EMS Industry Leader Commits to Retrofitting Helicopter Fleet with Crashworthy Fuel Systems

Earlier this summer, the NTSB asked the FAA to require helicopter manufactures to equip all new aircraft with crashworthy fuel systems.  If history is any guide, we can expect the FAA to ignore that recommendation, despite that the FAA has known of the dangers posed by existing fuel system for decades.

But now Air Methods, one of the nation's largest EMS helicopter operators, has committed toAir Methods EMS retrofit its entire fleet of more than 70 Airbus AS350 helicopters with fuel systems that don't needlessly catch fire in a crash. 

Air Methods is committed to retrofitting 100% of our Airbus AS350/EC130 (H125/H130) fleet, and we are working directly with a thried party who is seeking certification for a crash resistant fuel system for the entire Airbus line.. . . For us, it's about doing the right thing."

The program will be costly.  And Air Methods is taking the action entirely voluntarily.  The FAA does not now require retrofitting, and it's unlikely it ever will.   

But, as Air Methods says, maybe it is about doing the right thing, rather than the most profitable thing. The question is, will other operators follow?

HEMS Operator Drops Pretense That It's All About Speed

The air ambulance industry has a poor safety record.  Most of the industry crashes involve EMS helicopters rather than airplanes.  The EMS helicopter fatal accident rate is 6000 times that of commercial airliners.  As it turns out, flying an EMS helicopter is one of the most dangerous jobs inSkyHealth America.

The industry tries to justify the poor safety record by pointing to the “need for speed.”  While acknowledging that the risk of a crash is many times greater for a patient traveling in an EMS helicopter than a ground ambulance, the industry argues that the additional risk is justified because the patient riding in a helicopter usually gets to the hospital sooner.  

That argument has always been questionable. Now, however, it seems that at least one operator is dropping the pretense altogether.  According to SkyHealth, a brand new contractor providing helicopter services to Yale-New Haven hospital patients, it’s really not about speed at all.  It’s really about the equipment on board the helicopter.

When you’re talking about using the helicopter for critical-care patients, people think it’s all about speed. . .  But it’s not about getting to the hospital faster.  It’s really about being able to provide care during transport from one hospital to another.”

The new operator reports that it is flying patients every other day.  But it's not rushing trauma victims from accidents sites to emergency rooms as you might expect.  Instead, it is moving stable patients from one hospital to another.

With the copter, ‘you don’t have out of hospital time because the crew in the hospital can do the same things as the [ICU]. . .It’s a higher level of care than our ground transport.

Wouldn’t it be safer for these patients and cheaper to simply upgrade the care available in a ground ambulance? 

EMS Night Vision Goggles: FAA Incompetence Exposed

Stephen Stock, an investigative reporter for NBC, talks about the hazards posed by night vision goggles improperly installed in much of the nation's EMS helicopter fleet. I was happy to offer Stock my thoughts. The FAA refused to comment on camera.

Imagine how difficult it must be for Rand Foster to go to work each day.



Office of Special Counsel Warns of Gross Mismanagement at the FAA

In 2008, a safety inspector determined that nearly half of the nation's EMS helicopter fleet--about 300 aircraft--have improperly installed night vision systems. As installed, the systems are a hazard to the air ambulance crews and the patients they carry. The inspector felt the aircraft should be grounded until they were fixed. The FAA initially agreed, but then changed its mind. Apparently, the FAA decided to look the other way because of the "negative publicity" a grounding would generate.

Pretty alarming.  Ultimately, the United States Office of Special Counsel became involved, taking the unusual step of writing to President Obama.

[The United States Office of Special Counsel] found a substantial likelihood that FAA officials and employees engaged in violation of law, rule or regulation, gross mismanagement and an abuse of authority, all of which contributed to a substantial and specific danger to public safety.

It's been three years, but the White House has done very little.  So now the OSC has written the President again.

The OSC continues to be concerned about the improperly installed night vision goggle systems that plague the nation's EMS helicopter fleet.  But it is also concerned about a litany of other whistleblower complaints against the FAA that the OSC has received, investigated and substantiated.  The complaints range from FAA personnel allowing Delta Airlines to perform improper maintenance to air traffic controllers sleeping on the job.  The FAA is aware of the complaints, but has done little about them.

One senses a bit of frustration in the Special Counsel's latest letter:

This transmittal is the final chapter in OSC's formal oversight process. . .additional enforcement action rests with Congress or the White House.  Given the recurring and serious nature of these concerns, I write with a strong recommendation that more rigorous oversight measures be put in place at DOT and FAA to ensure a higher standard for aviation safety. 

OSC Letter FAA 2012

Legal System Treats Passengers Differently From Crew

When an EMS helicopter goes down, our legal system treats the family members of theTerry and VictorTacoronte passengers lost in the accident quite a bit differently from the families of the crew.  For example, while the family members of the passenger may perhaps get their day in court, the claims of the crew members' families are usually precluded by workers' compensation law.

We've talked about that before hereChristine Negroni, writing about a recent EMS helicopter crash in Kansas City, points out a case where that scenario seems to be playing out now.  The crash killed 58-year old Terry Tacoronte, who was a patient, along with the pilot, the flight paramedic, and the flight nurse. Due to workers' compensaton laws, it's likely that only Taraconte's widower will be permitted to press a lawsuit.

The law seems unfair to crew members.  But as Negroni writes, perhaps by pressing his case, the passenger's widower will make the industry safer for crew members going forward.

Helicopter Crash Lawyers Bribe Judge, Settle Case, Get Sued

EMS helicopter crash cases aren't easy.  A lawyer representing a victim's family ought to have experience in helicopter crash cases.  If he doesn't, he should bring into the case a lawyer who does.  What he should not do, obviously, is make up for lack of experience by bribing the judge. 

It's shocking to think that a lawyer would ever bribe a judge.  But that's what Texas lawyers Jim Solis and Marc Rosenthal did.   The judge admits itSo does Solis.  They bribed the judge for favorable pre-trial rulings, and then, after getting those rulings, they settled the helicopter crash case, Texas Lawyer Marc G. Rosenthalobtaining $15 million for the families involved. Out of the settlement, the attorneys ended up with a $5.2 million fee.

Now the attorneys are being sued by their clients. The clients want that $5.2 million back. According to the lawsuit:

Plaintiffs are innocent and without prior knowledge of Defendants' criminal acts. Not only did Defendant breach their fiduciary duties to their clients, but in doing so they dishonored the memories of Michael T. Sanchez and Raul Garcia.

Under the law of many states, a lawyer who violates legal or ethical rules can be required to forfeit his or her fee. 

But even if legally entitled to the fee, are plaintiffs morally entitled to it?  After all, how were the families harmed by the lawyers' scheme? The families ended up with a settlement which, presumably, they found acceptable.

Families who lose loved ones in a helicopter or other crash sue for money.  No doubt about that. But perhaps more importantly, victims' families sue for justice.  They pay their attorneys to expose wrongdoing and hold accountable those responsible for an accident.  Putting aside all else, the attorneys in this case simply didn't do that job. The Sanchez and Garcia families did not get what they paid for.  

The case is Sanchez v. Rosenthal et al.

"Golden Hour" and Other Myths from the EMS Helicopter Industry

Why does the public accept the EMS helicopter industry’s horrible safety record? Because the industry has sold the idea that it’s critical to deliver trauma victims to a hospital within the first “golden hour” after an injury.  While the industry acknowledges that the EMS helicopter accident rate is high, it argues that many more lives are saved by EMS helicopters than are lost.    

The logic is appealing.  But it doesn’t wash. Here’s why.

  • The Need for Speed.  Though helicopters are fast, when it comes to getting the patient to a hospital, a ground ambulance is often faster. At least in urban areas, ground ambulances are more widely distributed than EMS helicopters. That means a ground ambulance is more likely to be stationed closer to the trauma victim. A well-positioned ground ambulance can often get to the trauma victim and deliver him to a nearby hospital quicker than a helicopter can. By and large, a helicopter’s speed advantage is limited to rural environments, where ground ambulances are fewer and farther between. The helicopter’s speed advantage is overrated.
  • “Life Flights” That Aren’t.  At 12 year-old was airlifted from summer camp to a hospital in Austin, Texas after she hit her head in the shower. The bill for the flight was $16,000. Upon arrival at the emergency room, she was treated, and then sent back to her summer camp.  Such stories aren't unusual.  In fact, some studies show a third of all patients delivered to emergency room by helicopter are released without ever being admitted to the hospital.
  • Pricey Shuttles.  Many EMS helicopter flights are inter-hospital transfers merely shuttling patients between hospitals. Operators love these profitable gigs. One calls the transfer patients “golden trout,” and encourages pilots to “hook” every one they can, regardless of how bad the weather conditions. No matter that, since the patient is already at a hospital, these transfers seldom classify as “emergencies.”

This is not to say that EMS helicopters never make a difference for trauma victims.  But much less often then the industry would have us believe.  One study showed that, at most, only 22% of those transported by EMS helicopter to Silicon Valley hospitals could be considered to have "possibly" benefited from the air ambulance. Other studies suggest that, even in cases involving serious trauma, helicopter transport improves the patient’s outcome less than 5% of the time. That means that 95% of the time the helicopter exposes the critically injured patient to an unnecessary risk. 

The industry has oversold the need for EMS helicopters. The benefits simply do not outweigh the risks.

EMS Helicopter - Airplane Mid-Air at Shenandoah Valley Airport

The EMS helicopter was returning to Shenandoah Valley Regional Airport in Virginia, having dropped off a patient in nearby Charlottesville.  Reports differ on whether the Cessna was departing the airport or returning to the airport for landing.  The Cessna and the helicopter collided.  Though the helicopter landed safely, both occupants in the Cessna were killed.

No Control Tower

There’s no control tower at Shenandoah Airport. The primary means of preventing collisions at airports like Shenandoah is called “see and avoid.” That means that pilots are supposed to look out their windows, see other aircraft, and avoid them. 

Helicopters and Airplanes Don’t Mix Well

Though the "see and avoid" method may sound primitive, over the years it has worked well, and mid air collisions are relatively rare.  But helicopters don’t mix well with airplanes in a "see and avoid" environment.  Helicopters tend to fly slower than airplanes and, because they have a small cross section, they are hard for airplanes to spot -- especially when viewed from directly behind. 

Because of that, when near an uncontrolled airport, helicopter pilots are supposed to "avoid the flow" of airplane traffic.  In other words, as best they can, helicopters are supposed to stay out of the way of airplanes.  Sometimes that’s easy enough. For example, if the airplane traffic flies on one side of the airport (see below), the helicopters generally should fly on the other side. Or, the helicopter can fly at an altitude that is lower than the altitude at which the airplanes are flying.

 Fixed wing traffic pattern

The above diagram depicts a left-hand traffic pattern for fixed-wing (airplane) traffic similar to the pattern used at Shenandoah Airport.  Airplanes typically fly the traffic pattern at 1000 feet.  To avoid the flow of that traffic, helicopters might fly a right-hand traffic pattern on the other side of the runway, and fly no higher than 500 feet.

One question will be whether the Cessna was operating within the "flow" of fixed wing traffic when the collision occurred and, if so, why the EMS helicopter did not avoid that flow. 

Cessa Crash Site

The EMS Helicopter Industry's Business Model Leads to Unnecessary Crashes

Emergency Medical Services helicopters don’t get paid for being on call. They earn money only when transporting patients. But, when they do transport a patient, they are paid well -- up to $20,000 per trip.

The business model has worked out well for the industry. In fact, the number of EMS helicopters in service has quadrupled since 2002. But since an operator doesn’t get paid unless the helicopter carries a patient, there’s an incentive to fly the mission regardless of how adverse the conditions. And because operators are paid the same rate no matter what equipment they use, operators tend to use older helicopters, and to run them as inexpensively and as ill-equipped as possible.

Not surprisingly, the EMS helicopter fatal accident rate is, when compared to other forms of commercial N502MT - EMS Helicopter Crashaviation, off the charts.  In fact, with a crash rate that is 6000 times that of commercial airliners, flying an EMS helicopter is the second most dangerous job in America. Only working on a fishing boat is riskier.

Some of the reasons why EMS helicopters crash: 

  • Weather.  Inadvertent flight into clouds or fog can cause the pilot to become disoriented and lose control of the aircraft. Thunderstorms can bring a helicopter down in seconds. While accurate weather information is available for airport destinations, it is a rare commodity for the off-airport locations that EMS helicopters typically service. The lack of accurate weather information, coupled with economic pressure to complete the mission, takes a toll.
  • Unprepared Landing Sites. Helipads are designed so that there are no wires, trees or other obstacles for the helicopter to hit during landing or takeoff. The ground is firm and level so that the helicopter won’t roll over when it touches down.  But when responding to a call, EMS helicopters accept landing sites that have been neither surveyed for hazards nor otherwise prepared for helicopter traffic.
  • Terrain.  EMS helicopters crash into mountains, ridges, and hillsides with some regularity. Most of those accidents happen when it’s dark, foggy, or cloudy. “Controlled flight into terrain” is a leading cause of EMS helicopter crashes.
  • Mechanical Failure.  Rotor blades come off, engines fail, and pilots lose control of EMS helicopters due to defective parts or maintenance.

In Part II ("Golden Hour and Other EMS Myths"): With names like “Angel Flight,” “Mercy Flight,” and “Life Flight,” the EMS helicopter companies market themselves as indispensable life-savers. Is this just marketing hype, or are the benefits of helicopter transport really worth the risks?

Compensating the Families of the Mountain Lifeflight EMS Helicopter Crash at Doyle, California

Who can be held responsible for compensating the Mountain Lifeflight families, and who is immune from suit?   

Maintenance.  If faulty maintenance is proven to be the cause of this helicopter crash, the families can recover against the maintenance company, provided that the families can prove that the maintenance company was negligent.  There is an important exception, however.  The families cannot sue the company that performed the maintenance if that company was Mountain Lifeflight itself.  That's because the worker's compensation laws immunize a crew member's employer from suit brought by the crew member's family.  More on that here.

Pilot error.  There is no reason to believe that the crash was caused by pilot error.  To the contrary, as discussed here, it looks as though the crash was likely caused by a mechanical failure.  However, assuming for argument's sake that the crash was caused by pilot error, the workers' compensation laws prohibit the families from suing either the pilot's estate or the pilot's employer.

Design defect.  Other A-Star accidents similar to this one raise the question of whether the crash was caused by the helicopter's faulty design.  The families are entitled to sue the aircraft's manufacturer, Eurocopter, and get to the bottom of the design defect issue.  If the families prove that the crash was in fact caused by a defect in the design of the helicopter, then they can hold Eurocopter responsible.

But there is one hurdle the families must overcome before winning a design defect suit.  The accident helicopter, N5793P, was manufactured in 1982.  The General Aviation Revitalization Act, or GARA, immunizes manufacturers from liability from lawsuits arising from aircraft that are older than 18 years.  At first blush, it would seem that the families have no recourse against the manufacturer at all.  But there is an important exception to GARA.   If the accident occurred as a result of a new part that was installed on the aircraft less than 18 years before the accident, the manufacturer can't assert the defense, no matter how old the aircraft.  And it has been reported that N5793P had been completely rebuilt only a few years before the crash.  Therefore, even though the helicopter was manufactured more than 27 years ago, it's likely that most critical parts on the aircraft were less than 18 years old, and that GARA won't protect the manufacturer.

Mountain Lifeflight EMS Helicopter Crash Update

The NTSB's preliminary report on the crash contains little more than what was in the news accounts. The report does, however, offer one bit of new information.  The helicopter impacted on a magnetic heading of 230 degrees.  That heading is not in line with the route from Reno to Susanville.  While that might ultimately prove to be important, little can be made of that information without a careful examination of the layout of the terrain near the accident site and the roadway that the pilot might have been using to aid in his navigation.     

Though the information in the NTSB's official report is sparse, an NTSB spokesman did offer his expanded comments to Mary Pat Flaherty, a reporter for the Washington Post who has been following the poor EMS safety record during the past months. The NTSB's Ted Lopatkiewicz told Flaherty that the Mountain Lifeflight helicopter didn't have certain important safety equipment.  Lopatkiewicz was referring to the helicopter's lack of an autopilot, a ground proximity warning system, night vision goggles (discussed in this post), and other equipment necessary to navigate in poor weather.

But in this case the pilot was flying in good weather.  He did not collide with the ground because he could not see it.  Rather, as discussed here, it appears that the pilot crashed because of some type of mechanical problem with the helicopter.  It's unlikely the helicopter's lack of advanced equipment played any role in the accident at all. 

Related Posts:

Compensating the Families of the Mountain Lifeflight EMS Crash

Mountain Lifeflight EMS Helicopter Crash at Doyle, California

EMS Helicopter Safety: NTSB Pushes the Envelope

OSC: FAA Ignoring EMS Helicopter Dangers For Fear of Negative Publicity 

Mountain Lifeflight EMS Helicopter Crash at Doyle, California

An A-Star AS350B air ambulance helicopter crashed November 14 at Doyle, California, killing the A-Star Helicopter that Crashed Saturdaythree crew members on board.  According to an article in the Reno Gazette Journal, the pilot made a distress call before the crash. That indicates that the pilot was likely experiencing a mechanical emergency. The photographs accompanying the article show that the wreckage was spread over a fairly large area.  That indicates that the pilot lost control of the helicopter well before he was able to attempt an emergency landing.

Under the circumstances, the NTSB will be looking at the helicopter's

Continue Reading...

EMS Helicopter Safety: NTSB Pushes the Envelope

There's little question that EMS helicopters are the most dangerous aircraft in the sky. EMS helicopters have a fatal accident rate 6000 times that of commercial airliners. Flying EMS helicopters is one of the most dangerous jobs in America.  In fact, according to the Washington Post, only working on a fishing boat is riskier.  And the EMS helicopter safety record is getting worse, not better.

EMS helicopterWhy, exactly, is the EMS helicopter accident record so bad?  As discussed here, one problem is that it's not clear who is ultimately responsible for overseeing the industry. State agencies, county agencies and the federal government all have a hand in oversight but no one appears to be in charge. That means that definitive industry standards cannot be established and hazards cannot be effectively managed.

This week, the NTSB recommended that the FAA take steps to address the most serious of the industry's problems. Some of the those recommendations are not particularly surprising. For example, the NTSB suggests that pilots be better trained in bad weather flying, and that helicopters be equipped with night vision equipment and autopilots.

One of the NTSB's recommendations, however, no one saw coming.  The NTSB suggests that Medicare -- which funds most of the EMS helicopter industry by paying up to $20,000 for each patient transport -- adjust its rate reimbursement structure according to the level of safety the helicopter company provides.  In plain english, the NTSB suggests that Medicare not pay air ambulance companies unless they meet certain safety standards.  NTSB board member Robert Zumwalt concedes this recommendation "pushes the envelope".  But the air ambulance record is so bad, extreme steps are necessary.

By targeting the air ambulance industry's source of funding, the NTSB is looking beyond the FAA for help in making the air ambulance industry safer.  Why not just leave it to the FAA?  For one thing, the FAA has yet to act on the EMS helicopter recommendations the NTSB made 3 years ago.  The NTSB is hoping the Department of Health and Human Services (Medicare) will be more responsive to its safety concerns than the FAA has been. 

OSC: FAA Ignoring EMS Helicopter Dangers For Fear of Negative Publicity

The FAA is supposed to use its regulatory powers to promote aviation safety.  Over the years, however, it seems to have become too bureaucratic and conflicted to take decisive action when it counts most.  Examples:

Now, there's more.  In 2008, an FAA inspector determined that nearly half of the nation's EMS helicopter fleet--about 300 aircraft--have improperly installed night vision systems. As installed, the systems are a hazard to the air ambulance crews and the patients they carry.  The inspector felt the aircraft should be grounded until they were fixed.  The FAA initially agreed, but then changed its mind.  Apparently,  the FAA decided to look the other way because of the "negative publicity" a grounding would generate.

Huh?  Since when should the FAA be concerned more with negative publicity than with safety?

Recently, the United States Office of Special Counsel became involved.  Special Counsel, however, has been unable to get the FAA to respond to its inquiries.  So it has taken the unusual step of writing to President Obama.

[The United States Office of Special Counsel] found a substantial likelihood that FAA officials and employees engaged in violation of law, rule or regulation, gross mismanagement and an abuse of authority, all of which contributed to a substantial and specific danger to public safety.

The Office of Special Counsel appears more interested in EMS Helicopter safety than does the FAA.  We'll see what happens next.

OSC Letters

EMS Helicopter Crash Suits Subject to Medical Malpractice Restrictions?

Special rules protect careless health care providers in California.  The rules, collectively known as MICRA, were designed to make it harder for medical malpractice victims to sue the doctors who injure them. For example,

  • The medical malpractice victim must provide the defendant doctor a special notice before filing suit.
  • At any trial, special rules of evidence apply that favor the doctor.
  • There is a $250,000 limit on what the negligent doctor or his insurance company ever has to pay to compensate parents when the doctor causes their child's death.
  • An injured party cannot recover against a negligent doctor more than the $250,000 limit for causing any sort of pain or disfigurement. 

But what do the MICRA rules have to do with helicopter crash cases?

In March 2008, a California court of appeal ruled that the medical malpractice rules apply to the claims of a someone injured in an ambulance.  In that case, called Cannister v Emergency Ambulance Service, the court ruled that a negligent ambulance company that injures a patient en route to the hospital was entitled to all the EMS Helicopter by JPCprotections of MICRA, because the ambulance company was properly considered a “health care provider.” The ruling extended the umbrella of MICRA's protection from doctors to ambulance drivers, at least when those drivers are licensed as EMT’s.

An EMS air ambulance company will undoubtedly argue that Cannister -- regardless of how unfair -- applies not just to road-bound ambulances, but to air ambulances as well. The aviation lawyer must keep the MICRA rules in mind in handling EMS helicopter accidents in California, and he should be familiar with the strategies that medical malpractice lawyers use to minimize MICRA's unfair impact on his clients.  

Helicopter Air Ambulance Risks Identified

Flight Safety Foundation has released a study identifying the most significant risks involved in the helicopter air ambulance industry. The safety study was undertaken in response to the industry's increasingly poor safety record.

According to the 64 page report (pdf), one of the biggest problems is that it’s not clear who is in charge of overseeing the industry.  State agencies, county agencies, and federal agencies all have a hand in regulating air ambulance operations but there is little coordination between them. Because no one agency is clearly in charge, hazards cannot be appropriately identified or managed, and definitive industry standards cannot be established.  

The report went on to identify 25 other significant risk factors.  Among the problems discussed:

  • Good decisions aren’t being made about whether a patient actually needs air transport.  Unnecessary flights lead to increased crew pressure and fatigue.
  • The industry lacks a real “safety culture.”  That can give rise to environments that reward inappropriate risk-taking behavior.
  • There is not enough money available to upgrade the EMS helicopters with current technology.

The report was underwritten by Bell Helicopter.  Though interesting reading, there's little in the report that those familiar with the air ambulance industry would find surprising.

More on the NTSB and Air Ambulance Accidents

A reader of this post concerning air ambulance accidents asked, “Can the FAA really get away with ignoring the NTSB?"  The answer, to date, is "yes."  And there's nothing the NTSB can do about it.

The whole reason the NTSB exists is to learn from accidents and make safety recommendations so that similar accidents won’t happen again. But the NTSB has no power to make anyone, including the FAA, follow its recommendations.  And so, frequently, the FAA just ignores them.

Of course, ignoring NTSB recommendations can lead to loss of life. Some feel that the crash of Continental Flight 3407 in Buffalo might have been avoided, and 50 lives saved, had the FAA acted on the NTSB’s safety recommendations concerning turboprop planes and airframe ice. But the FAA never did, despite that some of those recommendations are now more than 10 years old. Even by goverment standards, ten years is a long time to sit on something. 

But back to air ambulances: The NTSB studied 55 air ambulance crashes occurring between 2002 and 2004 in which 54 people were killed.  As a result of what it learned, the NTSB recommended (pdf) that air ambulance companies be required to, among other things: 

  • equip their helicopters with terrain warning systems;
  • ensure that their pilots have good weather information before taking off; and
  • ensure that their pilots get adequate rest. 

All straightforward stuff that is hard to argue with. 

That was back in 2006.  Since then, another 9 air ambulances have crashed, killing 35.  Still, the FAA hasn't acted on the recommendations. Though there has been some response from the FAA, the NTSB calls the response "unacceptable." 

One might wonder: if the FAA is free to ignore the NTSB, and has a record of doing just that, then what’s the point of even having an NTSB?

Good question.

NTSB: Air Ambulances Drag Down 2008 Accident Statistics

Well, that seems to be what the National Transportation Safety Board said today when it commented on the preliminary accident statistics for 2008.

The NTSB's comment:

The 2008 accident statistics reveal a mixed picture. . . We are particularly concerned with the spike in fatalities in on-demand air charter operations. There's a lot of room for improvement in this area, and as evidenced by our recent forum on emergency medical service helicopter accidents, we continue to do everything we can to identify the safety issues involved, and to advocate for the adoption of our recommendations that will make the skies safer.

Our Translation"The 2008 accident statistics wouldn't look bad except for all the air ambulance helicopter crashes.  We've got some ideas on how to make air ambulance operations safer, but the FAA keeps ignoring us.  As usual."