Estimated reading time 17 minutes, 15 seconds.
“Safety is our number one priority.”
This is a common mantra that echoes often from every corner of the air medical transport industry, from local organizations to the federal government.
Is it, though? Really?
If we take safety that seriously, we should be heavily invested in truly understanding the complexities of accidents within our industry. However, 322 people perished in the line of duty in helicopter emergency medical services (HEMS) in the United States between 1972 and 2015, and there were 691 survivors of accidents with varying degrees of injuries. And yet, if I were to ask anyone in the industry, the U.S. National Transportation Safety Board (NTSB), or the Federal Aviation Administration (FAA) a question like, “How many of those survivors sustained spinal cord injuries that may have been mitigated by energy-attenuating seats?” the answer would be, “We don’t know.”
“How many people were burned in post-crash fires in HEMS crashes?”
“We don’t know.”
“How many sustained blunt traumatic injuries and what was the mechanism of injury?”
“We don’t know.”
“What are costs of injuries for those who survive HEMS crashes?”
“We don’t know.”
“How do we find out what types of injuries occupants have sustained in HEMS crashes so we can better understand how to prevent them?”
“We don’t know.”
“What do we know about injuries to occupants in HEMS crashes?”
“We know whether they were fatal, serious, minor, or uninjured.”
“How does a vague description like that help us prevent similar injuries from occurring in the future?”
“We don’t know.”
We’ve had over 40 years to better understand HEMS crashes. It’s hard to believe that decisions pertaining to safety could be made soundly with the abject lack of detailed accident, injury, and outcome data in the industry. Still, after over four decades of existing as an industry, there is seemingly little to no forward movement on improving data collection, analysis, and subsequent action to decrease the morbidity and mortality of our own.
Despite some improvements in safety, HEMS accidents continue to occur at an alarming rate. Our crewmembers, as well as some patients, are losing life and/or limb in what are often preventable crashes and in what, in some cases, should have been survivable impacts.
Mathematically minded people turn to the cost-benefit analysis to determine whether or not safety measures are a worthwhile investment. But let’s return to an earlier question: what are the detailed causes and costs of injuries, including fatal injuries, of HEMS crashes?
With the myriad of cost-benefit analyses that have most certainly been done regarding safety upgrades, one might surmise that this information would be readily available.
The disturbing reality is, it isn’t. Not at the FAA, not at the NTSB, and not in the HEMS industry. In fact, detailed injury data for helicopter occupants (survivors and fatalities) in crashes doesn’t exist anywhere. (That’s probably why conversations regarding some safety upgrades in HEMS often end up in schoolyard, “Yes huh” — “Nuh uh” arguments. Just bring up the single-engine vs. twin-engine discussion in a room full of HEMS people and you’ll see what I mean.) We often base our arguments on passionate opinions, our own best interests, and sometimes, pure mythology. And helicopters are still crashing, and our people and patients are still getting needlessly injured and killed.
So how are we making sound decisions when it comes to investing in safety? Where are the data? How can we say that safety is our number one priority if we don’t bother to pursue the facts? How can we pursue the facts without the personnel and systems to do that? How can we address the actual causes of morbidity and mortality in this industry if we don’t do the research? Sadly, there are far more autopsy and injury data on the accident aircraft than on the people who occupied them at the time of the crash.
The burning question is: how are cost-benefit analyses done and safety decisions being made without knowing the cost of injuries and fatalities? How have these decisions been made historically without this major piece of the equation? I suspect that our current situation has allowed for gross underestimation of justifiable investments in safety, from crash prevention to crash survival.
The Value of Reducing Risk
Since the HEMS industry lacks any kind of comprehensive surveillance, data collection, and analysis system, we must turn to other industries that actually do have valid and scientific methods for measuring, reporting, and acting upon the true causes of morbidity and mortality.
The U.S. National Highway Traffic Safety Administration (NHTSA) has sophisticated surveillance systems, data collection/analysis, and the means to take action to decrease morbidity and mortality with regard to motor vehicle crashes. To quantify the benefit of preventing a fatality, it has adopted the concept of the Value of a Statistical Life (VSL), which is defined as the additional cost that individuals would be willing to bear for improvements in safety that, in the aggregate, reduce the number of expected fatalities by one.
The VSL is often misinterpreted as “the value of a life” — it’s not. Instead, it’s a measure of the implied value that consumers place on their lives, as revealed by the price they are willing to pay to avoid the risk of death. Estimates of this “willingness to pay” come through studies that examine wage rate differentials for risky jobs, or the prices that consumers pay for products that reduce their risk of being fatally injured.
For analysis conducted in 2015, Office of the Secretary of Transportation (OST) guidance suggests that US$9.4 million be used as the current estimate for the VSL, measured in 2014 dollars. This estimate is also used to determine the value of averted injuries in combination with the Maximum Abbreviated Injury Scale (MAIS), a comprehensive system for rating the severity of accident-related injures. MAIS classes non-fatal injuries into five categories depending on the short-term severity of the injury, with a sixth category corresponding to injuries that result in death 30 or more days after the accident (see Table 1).
A valuation for each MAIS injury severity level is determined by estimating the loss of quality and quantity of life resulting from an injury typical of that level, with the loss expressed as a fraction of the VSL. Those fractions and their current dollar value estimates can be seen in Table 2 — for example, the value of averting a minor injury is currently $28,200, while the value of averting a critical injury is more than $5.5 million.
While HEMS research has traditionally focused on fatal accidents, it is essential that we consider the fact that non-fatal injuries are more common, and vary significantly in terms of severity, outcomes, and cost. Surviving a crash with severe burns, spinal cord injury, or other severe debilitating injury requiring care for the remainder of a lifetime can be far more costly than the current VSL for fatalities.
As referenced earlier, the NTSB classifies injuries in aviation accidents only as “fatal,” “serious,” or “minor.” A “fatal” injury is one that results in death within 30 days of the accident, while a “serious” injury “refers to any injury that (1) requires hospitalization for more than 48 hours, commencing within seven days from the date the injury was received; (2) results in a fracture of any bone (except simple fracture of fingers, toes, or nose); (3) causes severe hemorrhages, nerve, muscle, or tendon damage; (4) involves injury to any internal organ; or (5) involves second- or third-degree burns, or any burns affecting more than five percent of the body surface.” (The NTSB does not provide a specific definition for “minor injury.”)
In other words, any injury from a broken arm to severe third-degree burns can be classified as “serious,” providing absolutely no specificity when it comes to retrospectively reviewing this data. This poses significant problems when trying to determine the nature of injuries occupants sustain in helicopter crashes and, consequently, how to mitigate those injuries.
It should also be noted that it is likely that injuries are under-reported. There are anecdotal examples of occupants whose injuries were not immediately apparent, but caused disability beyond the immediate post-crash timeframe. Even “minor” injuries can be career-ending for those who work in aviation. Incidences of post-traumatic stress disorder (PTSD) are also under-reported and require far more research as well, as unmitigated PTSD and other “unseen injuries” can have costly ramifications. Moreover, addiction to pain medications can arise as people try to manage their pain from injuries, resulting in another costly variable.
The lack of specificity with regard to injuries, as well as the lack of information on the mechanisms of injury and death, makes accurate injury analysis within the current database difficult, if not impossible. If the NTSB utilized the MAIS scale for injury classification, then the valuation of injuries could be determined more accurately.
Since the NTSB injury classification system does not include all six MAIS categories, the U.S. Office of Aviation Policy and Plans (APO) had to develop another method to make the calculation of injury valuations possible (see Table 3). The APO determined that “minor” injury victims typically (but not always) have injuries at the MAIS 1 level only, corresponding to the fractional fatality value of 0.003 and a current dollar value of $28,200. Meanwhile, it determined that “serious” injury victims typically have at least one injury at MAIS 2 or higher, so it took a simple average of the values for MAIS 2 to MAIS 5. This resulted in a fractional fatality value of 0.253 — which has a current dollar value of $2,378,200, given the VSL for a fatal injury of $9.4 million.
Practical Application to HEMS Crashes
It should be noted that Lawrence Blincoe, author of the NHTSA’s The Economic and Societal Impact of Motor Vehicle Crashes, suggests that “taking a simple average of the MAIS 2-5 disutility factors will overstate the average disutility for that group. The proper way would be to compute an average weighted by relative incidence of injuries in each category.” Nevertheless, the APO’s estimates provide a starting point for estimating the impact of the past 10 years of HEMS crashes, especially considering that the number and impact of injuries are likely under-reported.
According to the NTSB’s Aviation Accident Database, between 2006 and 2015, there were 90 HEMS accidents, resulting in 103 fatalities, 31 occupants with serious injuries, and 24 occupants with minor injuries (an additional 130 occupants were said to have no injuries). If we apply the existing VSL dollar values to these totals, we can determine that the fatalities had a combined disutility of $968,200,000; the serious injuries, a combined disutility of $73,724,200; and the minor injuries, $676,800 — resulting in a staggering total impact of $1,042,601,000. Yes, that’s more than a billion dollars.
These numbers by no means illustrate the comprehensive costs of HEMS crashes; rather, they are likely the tip of the iceberg. It is highly unlikely that all of those categorized as having “no injuries” truly had no injuries. As there is no follow up with crash survivors, there is also little data, other than anecdotal, to know if the initial injury assessments were correct to begin with. But, with the lack of any other system to calculate injury costs in this industry, it’s a start.
And here’s another important question: Who pays?
The costs conservatively add up to over a billion dollars over the past 10 years. Maybe insurance companies cover some of it, but it is quite feasible that most of it creates an insidious and unseen burden that is absorbed by society. And there is no question that the survivors of HEMS crashes, their families, and the families of the fallen bear the lion’s share of this unimaginable economic and non-economic burden.
Another way of determining costs is through determining comprehensive unit costs as in the Summary of Comprehensive Unit Costs utilized by NHTSA (see Table 4). The costs listed in each category in NHTSA’s table are clearly far below what they would be in HEMS. Take “EMS” costs for example. Many survivors of HEMS crashes are transported by helicopter from the scene of their crash to a trauma center. The air medical transport costs alone far exceed the listed “EMS” costs on the NHTSA table, even for an MAIS 5. The HEMS industry would need to determine more accurate values in order to calculate costs. However, the HEMS industry currently does not have the data to fill in a similar table (see Table 5). How can we effectively manage what we do not measure?
These comprehensive costs need to be determined. Only when we understand the true costs of these crashes, both economic and non-economic, can we effectively address the accidents and injuries in HEMS. While the numbers discussed thus far represent economic costs — such as medical care, lost productivity, and legal and workplace costs — it is extremely important to additionally consider the non-economic costs of HEMS crashes.
As noted in the NHTSA’s most recent version of The Economic & Societal Impact of Motor Vehicle Crashes, in the case of serious injury or death, “medical care cannot fully restore victims to their pre-crash status, and human capital costs fail to capture the relatively intangible value of lost quality-of-life that results from these injuries.” In the case of death, of course, the victim is deprived of his or her remaining lifespan. In a case of serious injury, the victim may suffer lifelong disability and pain “beyond any economic recompense.” Moreover, a victim’s friends and family may also suffer economic losses and profound emotional burdens in caring for the victim.
The authors of the NHTSA paper state, “Action taken by society to alleviate the individual suffering of its members can be justified in and of itself; in order to increase the overall quality-of-life for individual citizens. In this context, economic benefits from such actions are useful to determine the net cost to society of programs that are primarily based on humane considerations. If the focus of policy decisions was purely on the economic consequences of [crashes], the most tragic, and, in both individual and societal terms, possibly the most costly aspect of such crashes would be overlooked” (emphasis added).
The Big Picture
The next time someone suggests that the “benefit doesn’t justify the cost” of a safety improvement, consider this: between 1972 and 2015 there were 1,013 individuals involved in HEMS accidents in the U.S. That’s enough people to fill two Boeing 747s. Of those individuals, 322 were fatally injured, 113 were classified as having “serious” injuries, 131 had “minor” injuries, and 447 were classified as “uninjured.”
What do we know about them beyond that? Not much. But most certainly the economic costs are far into the billions of dollars, and the non-economic costs to crash survivors, families of our fallen, and to the community as a whole are immeasurable.
The injury costs discussed in this article, both economic and non-economic, are clearly understated, as the comprehensive data required to ascertain more accurate numbers does not exist. Further, these costs do not reflect the comprehensive costs of HEMS crashes. If we are to truly understand how to decrease our own morbidity and mortality, then we must be committed to establishing the rigorous data collection and research methods utilized by entities such as NHTSA.
Finally, data alone will not tell the whole story. It is essential that we seek to understand the experiences of crash survivors and surviving family members so that we can develop the means to mitigate both economic and non-economic costs of crashes.
While there is no amount of money that can make up for the loss of life or limb, the financial calculations in this article are intended to spark a conversation about better understanding the true costs of injuries sustained in HEMS crashes so that the costs of safety improvements can be readily justified. What costs are we willing to bear to improve safety and reduce risks? If safety is truly our number one priority, then we should be making every attempt to fully understand all of the realities of crashes and determine a reality-based approach to safety — from preventing crashes to improving crash survivability, to ultimately learning as much as possible from near-misses, as well as accidents.
The FAA is required to determine the economic impact of implementing safety measures; for example, crash-resistant fuel systems and energy-attenuating seats in helicopters. Equally important, however, is determining the cost of not implementing these and similar measures, which seemingly has been overlooked. The costs to crash survivors, surviving family members, and society as whole from preventable deaths and injuries can no longer be ignored.
As this story goes to press, a flight nurse is struggling for his life in a burn intensive care unit in Colorado, where he has been for the past 11 months. He was severely burned in a post-crash fire that was likely entirely preventable. And he is not the first one to endure such devastating injuries — similarly preventable accidents have occurred, in which other air medical crewmembers literally burned alive. Why? Because somebody somewhere decided that the benefit of integrating crash-resistant fuel systems was not worth the cost.
These types of preventable deaths and injuries cannot be allowed to continue to happen.
The normalization of deviance is defined as the gradual process through which unacceptable practice or standards become acceptable, becoming the social norm for an organization as deviant behavior is repeated without catastrophic results. In the helicopter industry, a normalization of deviance has occurred even with a history of catastrophic results, as segments of the helicopter industry — despite hundreds of deaths and injuries over the past decades — continue to balk at crucial safety recommendations and regulations from the NTSB and the FAA.
The popular definition of insanity, meanwhile, is to keep doing the same thing over again and expecting a different result. We’ve recently lost three more crewmembers and a patient in yet another HEMS crash. That would be a minimum of $37,600,000 in injury costs alone, and immeasurable pain and suffering for the families and friends left behind. Let’s stop the insanity. Let’s actually strive to truly understand what we’re trying to solve, and let’s enlist the expertise of those who understand what we clearly do not.
Our crews and their families, as well as the patients we fly, deserve nothing less.