FAA Office of Aerospace Medicine 
Civil Aerospace Medical Institute

Report No: DOT/FAA/AM- 24/22

Title and Subtitle: Human Factors Analysis of Helicopter Air Ambulance Accidents, Incidents, and Events (2013-2023)

Report Date: November 2024

Authors: Hannah M. Baumgartner, Justin Durham, Rebecca DiDomenica, Peter T. Hu

Abstract: Helicopter Air Ambulance (HAA) operations are subject to unique risks due to their time-sensitive and safety critical nature. The Civil Aerospace Medical Institute (CAMI) completed analyses of the National Transportation Safety Board’s(NTSB) Case Analysis and Reporting Online (CAROL) aviation accident and serious incident database and the National Aeronautics and Space Administration’s (NASA) Aviation Safety Reporting System (ASRS) data over a 10-year span. In total, 102 ASRS reports, 53 final NTSB accident reports, and 3 final NTSB incident reports involving HAA from 2013 to 2023 that occurred within the United States (U.S.) were coded for human factors and organizational risk factors. The analyses identified several human factors risks impacting HAA flight crew related to situation awareness(SA), judgment and decision-making (JDM), adherence to procedures, and experience and training. Further, organizational issues influencing HAA operations, such as communication, safety culture, and those involving operator policy and procedure, were identified. Research recommendations based on the findings broadly involve investigating techniques to improve SA, reevaluating or assessing training needs, and providing additional resources for pilots and flight crews in HAA operations.

Key Words: Helicopter air ambulance, accident analysis, human factors, NTSB, ASRS

No. of Pages: 35