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but recognized a subgroup where rapid transport was useful (epidural hematomas, vascular compromise/open fractures, and penetrating neck/trunk injuries) Safety of the transport personnel must also be a priority Avoiding the use of RW transport in bad weather is a good example of a safety decision in the transport environment Improvements in HEMS safety profiles were recognized when pilots were isolated from specific patient care information for transport requests Instead of being informed that a critically ill child might die without their intervention, pilots now should make “go” or “no go” decisions based solely on weather, flight personnel, and equipment issues If an appropriate “no go” decision is made, this should not be questioned or countermanded by medical or administrative personnel If a “no go” decision is made based on weather considerations, another mode of transport or other patient care options must be considered Competition between transport programs or aeromedical providers can be a safety hazard In efforts to gain a competitive advantage, programs (or specific personnel) may be willing to consider circumventing weather and safety rules Optimal policies for safety-conscious systems include when a transport is denied by one air service for weather-related issues, those same transports are not offered to another air service unless it is located in a different environment that may not be subject to the same weather issues Unfortunately, the HEMS industry has seen periodic increased accident and fatality rates Compared to ground ambulance transport (15 million annual patient exposures), the fatal accident rate is greater for helicopter transport by approximately 13.5 times, however in the last three decades the accident rate in HEMS has declined by 71% In 2006, the National Transportation Safety Board (NTSB) critically reviewed 55 HEMS accidents and found that over half of the fatalities could have been prevented with systematic corrective actions This review resulted in safety initiative recommendations, which are outlined in the NTSB publication, Special Investigative Report on Emergency Medical Services Operations, available at www.ntsb.gov The following recurring safety issues were noted: (i) Less stringent requirements for EMS operations conducted without patients on board, (ii) lack of aviation flight risk-evaluation programs for EMS operations, (iii) lack of consistent, comprehensive flight dispatch procedures for EMS operations, and (iv) no requirements to use technologies such as terrain awareness and warning systems (TAWS) to enhance EMS flight safety Interventions by the FAA have resulted in safety improvements, including certification of night vision goggles (NVG) for helicopter use Other recommendations include TAWS, more stringent flight operation requirements, improved preflight risk management and hazard identification, and mitigation