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?

  • Cloudesley Shovell

    Regarding the back side of the clock flying, I wonder what the actual rate is. For example, if only 25% of flights happen 2200-0600, then the rate is much worse that daytime flights. However, if half the flights happen during that time period, then the fact that half the crashes happen during that time is unremarkable. I couldn’t find more precise data in the link.

    My personal opinion is that medivac helicopters are an incredible waste of money. I poked around a bit and found the assertion that “There is no scientific evidence that medical helicopters save lives.” http://www.ems1.com/ems-products/ambulances/articles/404642-Alright-Ill-Say-It/ (The author, Dr. Bledsoe, provides contact info at the bottom of the link–maybe he can help you with more specific information if you’re interested).

    Look forward to the second half of your post.

  • Mike Danko


    As it turns out, about 38% of all EMS flights are conducted at night. "A Safety Review and Risk Assessment in Air Medical Transport." Supplement to the Air Medical Physician Handbook, (November 2002), Page 16 (pdf) (I’m surprised the percentage is that high.)

  • Cloudesley Shovell

    Mike-I’m surprised, too. I thought the rate would be far worse at night than day.

    A couple things jumped out at me in that very interesting article…wx-related mishaps went way up at night compared to day. Not surprising-it’s much harder to discern approaching IMC wx at night. Second was the number of mishaps that occurred in cruise flight. I thought that was disproportionate compared to takeoff/landing.

    I also noticed the dramatic increase in helicopter use just from 1980 to 1988–21000 hrs to over 120,000 hrs flown in just 8 years, with a similar magnitude increase in patients flown. Wow. I have to imagine that there are some pretty hefty economic incentives helping to drive the explosive increase in helicopter use. I suppose the closing of more rural and small-town hospitals and centralizing hospital care in larger cities could be a driver. May well be cheaper to centralize care and fly the patients in rather than keep a lot of underutilized hospitals open. Then again, how many patients really need to be flown? Would a 90-minute ambulance ride be just as safe as a 30-minute helicopter flight?

  • Mike Danko

    “I suppose the closing of more rural and small-town hospitals and centralizing hospital care in larger cities could be a driver.”

    What’s interesting is the circular logic that feeds this phenomenon. Rural hospitals are being closed because EMS helicopters can quickly get the patient to an urban medical center. The risks of EMS helicopter transport are deemed necessary and acceptable because rural hospitals are being closed.

  • Cloudesley Shovell


    Based on some googling, looks like another driver of the dramatic increase in helicopter use is the fact that Medicare now reimburses for their use. The industry was successful in lobbying either for a good increase in reimbursement rates, or reimbursement in the first place. I’m sure that’s a big driver of the increase as well.


  • Mike Danko

    No doubt that Medicare is the lifeblood of the industry. With that in mind, last year the NTSB recommended to Medicare that it adjust its rate structure to account for the level of safety the helicopter company provides. In other words,the NTSB suggested that Medicare not pay air ambulance companies the full rate unless they prove that they have equipped their aircraft appropriately and otherwise meet certain safety standards. 
    The NTSB took some heat because some thought that sort of suggestion was not an appropriate “safety recommendation” at all. And the NTSB conceded it isn’t its place to get involved in that sort of policy discussion. But the air ambulance record is very bad and nothing seems to be working to improve it. The NTSB felt that appealing to the industry’s source of funding was something it had to try.

    Unfortunately, Medicare (or, more accurately, the Department of Health Services) has ignored the suggestion.