Proposed Rule2026-15929
Improving Emergency Medical Kit Efficacy and Flexibility in Commercial Airline Operations
Primary source
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Published
August 5, 2026
Issuing agencies
Transportation DepartmentFederal Aviation Administration
Abstract
FAA proposes to eliminate the prescriptive list of required items in emergency medical kits and first aid kits and replace it with a performance-based requirement to ensure contents are practical and sufficient to allow crewmembers to address the most common medical emergencies that occur onboard commercial aircraft. FAA seeks to increase flexibility for operators while maintaining predictability for operators to equip their onboard medical kits. This rule would also remove an outdated reference to certain emergency medical kits modified on April 12, 2004. This action is necessary to address requirements in the FAA Reauthorization Act of 2024.
Full Text
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<title>Federal Register, Volume 91 Issue 149 (Wednesday, August 5, 2026)</title>
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[Federal Register Volume 91, Number 149 (Wednesday, August 5, 2026)]
[Proposed Rules]
[Pages 50496-50511]
From the Federal Register Online via the Government Publishing Office [<a href="http://www.gpo.gov">www.gpo.gov</a>]
[FR Doc No: 2026-15929]
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DEPARTMENT OF TRANSPORTATION
Federal Aviation Administration
14 CFR Part 121
[Docket No. FAA-2026-9178; Notice No. 26-12]
RIN 2120-AM18
Improving Emergency Medical Kit Efficacy and Flexibility in
Commercial Airline Operations
AGENCY: Federal Aviation Administration (FAA), Department of
Transportation (DOT).
ACTION: Notice of proposed rulemaking.
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SUMMARY: FAA proposes to eliminate the prescriptive list of required
items in emergency medical kits and first aid kits and replace it with
a performance-based requirement to ensure contents are practical and
sufficient to allow crewmembers to address the most common medical
emergencies that occur onboard commercial aircraft. FAA seeks to
increase flexibility for operators while maintaining predictability for
operators to equip their onboard medical kits. This rule would also
remove an outdated reference to certain emergency medical kits modified
on April 12, 2004. This action is necessary to address requirements in
the FAA Reauthorization Act of 2024.
DATES: Send comments on or before October 5, 2026.
ADDRESSES: Send comments identified by docket number FAA-2026-9178
using any of the following methods:
<bullet> Federal eRulemaking Portal: Go to <a href="http://www.regulations.gov">www.regulations.gov</a> and
follow the online instructions for sending your comments
electronically.
<bullet> Mail: Send comments to Docket Operations, U.S. Department
of Transportation (DOT), 1200 New Jersey Avenue SE, West Building, 5th
Floor (W58-213), Washington, DC 20590.
<bullet> Hand Delivery or Courier: Take comments to Docket
Operations in Room W58-213 of the West Building 5th Floor at 1200 New
Jersey Avenue SE, Washington, DC 20590 between 9 a.m. and 5 p.m.,
Monday through Friday, except Federal holidays.
<bullet> Fax: Fax comments to Docket Operations at (202) 493-2251.
Docket: Background documents or comments received may be read at
<a href="http://www.regulations.gov">www.regulations.gov</a> at any time. Follow the online instructions for
accessing the docket or go to the Docket Operations in Room W58-213 of
the West Building 5th Floor at 1200 New Jersey Avenue SE, Washington,
DC 20590 between 9 a.m. and 5 p.m., Monday through Friday, except
Federal holidays.
FOR FURTHER INFORMATION CONTACT: Dr. Charles Mathers, Office of
Aerospace Medicine, Federal Aviation Administration, 800 Independence
Avenue SW, Washington, DC 20591; telephone (202) 267-3535; email <a href="/cdn-cgi/l/email-protection#5a63771c1b1b77173f3e33393b3677092e3b343e3b283e29773b343e771d2f333e3b34393f1a3c3b3b743d352c"><span class="__cf_email__" data-cfemail="1c25315a5d5d31517978757f7d70314f687d72787d6e786f317d7278315b6975787d727f795c7a7d7d327b736a">[email protected]</span></a>.
SUPPLEMENTARY INFORMATION:
List of Abbreviations and Acronyms Frequently Used in This Document
AED: Automated external defibrillator
AsMA: Aerospace Medical Association
EMK: Emergency medical kit(s)
FAK: First aid kit(s)
UPK: Universal precaution kit(s)
Table of Contents
I. Executive Summary
A. Overview of the Proposed Rule
B. Statement of the Problem
C. Summary of the Costs and Benefits
II. Authority for This Rulemaking
III. Background
A. 2024 FAA Reauthorization
B. History
C. 2025 Aerospace Medical Association Report
IV. Discussion of the Proposal
A. Appendix A to Part 121
B. Crewmember Training
C. Crewmember Training for In-Flight Medical Events (Sec.
121.805)
V. Regulatory Notices and Analyses
A. Regulatory Impact Analysis
B. Regulatory Flexibility Act
C. International Trade Impact Assessment
D. Unfunded Mandates Assessment
E. Paperwork Reduction Act
F. International Compatibility
G. Environmental Analysis
VI. Executive Order Determinations
A. Executive Order 13132, Federalism
B. Executive Order 13211, Regulations That Significantly Affect
Energy Supply, Distribution, or Use
C. Executive Order 13609, International Cooperation
D. Executive Order 14192, Unleashing Prosperity Through
Deregulation
VII. Additional Information
A. Comments Invited
B. Confidential Business Information
C. Electronic Access and Filing
D. Small Business Regulatory Enforcement Fairness Act
I. Executive Summary
A. Overview of Proposed Rule
FAA proposes to revise 14 CFR 121.803, Emergency medical equipment,
and remove and reserve Appendix A to 14 CFR part 121 (``Appendix A''),
First Aid Kits and Emergency Medical Kits, and replace that appendix
with the proposed new performance-based requirement in new Sec.
121.807. These changes would ensure the content of each kit is
practical and sufficient to
[[Page 50497]]
allow crewmembers to address common emergency illnesses or accidents
that may occur onboard commercial aircraft. This proposal would also
remove an unnecessary reference to kits modified on April 12, 2004,
from Sec. 121.805, Crewmember training for in-flight medical events.
FAA's intent is to increase flexibility in the manner in which
operators equip their onboard medical kits and train personnel for
their use.
This proposal is necessary to address section 368 of the FAA
Reauthorization Act of 2024 (``2024 FAA Reauthorization'') that
directed FAA to issue a notice of proposed rulemaking regarding first
aid kit (FAK) and emergency medical kit (EMK) equipment and training
required for flight crewmembers. It would also replace prescriptive
language in the existing regulation that cannot be kept current with
new, flexible requirements and advances in medicine and would reduce
further resource expenditure by stakeholders and FAA for Appendix A
exemptions.
B. Statement of the Problem
The 2024 FAA Reauthorization directed FAA to propose a rule
regarding FAK and EMK equipment and training required for flight crew
members. The 2024 Reauthorization directed that the proposed rule
consider the benefits and costs of any new medications or medical
equipment to address the emergency medical needs of children and
pregnant women, opioid overdose reversal, anaphylaxis, and cardiac
arrest. The 2024 Reauthorization further directed the proposed rule to
consider to what extent EMK should be readily available for use by
flight crews without prior approval by a medical professional.
In addition, FAA is proposing to address other problems it has
identified, such as those related to Appendix A to part 121. The
problem with the current Appendix A is it prescribes specific
medications and quantities of each medical item. Medical science and
medication innovation often evolve, and FAA's proposal would allow
operators' EMK or FAK to evolve with them.\1\ However, Appendix A's
prescriptiveness that specifically names certain medications and
specific quantities of each medication in the EMK prevents operators'
EMK or FAK contents from keeping up with the most modern medical
scientific developments.
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\1\ FAA uses the term EMK and FAK to refer to emergency medical
kits and first aid kits in general, respectively. For purposes of
this rulemaking document, FAA uses the abbreviation ``EMK'' and
``FAK'' to refer to both the singular and plural of those kits.
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In addition, medication shortages occasionally impact operators'
abilities to acquire an adequate supply for their EMK. An incomplete
EMK prevents an operator from operating the aircraft because this kit
is considered a ``GO/NO-GO'' item.\2\ When a shortage impacts one or
more medications required in an EMK, then all affected aircraft are
removed from service. In these instances, operators or trade
associations may petition FAA for relief from the prescriptive list of
kit items.\3\ FAA grants an exemption from a regulation if the
petitioner shows that granting the relief is in the public interest and
would not adversely affect safety.\4\ This process is resource-
intensive for both the petitioner and FAA. For that reason, FAA seeks
to end the need for regular exemptions by initiating this rulemaking
action. These proposed regulatory changes would alleviate these
resource concerns.
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\2\ See 14 CFR 121.803(a).
\3\ FAA approved 14 exemptions to address shortages in the EMK
since 2015: Spirit Airlines, Inc. (FAA-2025-0521); Airlines for
America, the National Air Carrier Association, Cargo Airline
Association, and the Regional Airline Association (FAA-2021-0706)
(19 operators exercised this exemption relief) Spirit Airlines, Inc.
(FAA-2025-0522); Ameristar Air Cargo, Inc. (FAA-2017-0780); Airlines
for America/National Air Carrier Association/Regional Airline
Association (FAA-2013-0034) (29 operators exercised this exemption
relief) NOTE: this docket contains seven exemptions/amendments for
exemption number 10690 over the past ten years; Airlines for
America, the National Air Carrier Association, Cargo Airline
Association, and the Regional Airline Association (FAA-2021-0706);
Aerodynamics Inc. (FAA-2019-0014); Vision Airlines (FAA-2016-8158).
\4\ 14 CFR 11.81.
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C. Summary of the Costs and Benefits
The proposed rule would create new flexible EMK and FAK
requirements, potentially reducing the risk of negative health outcomes
during part 121 operations. The new flexible requirements would also
result in cost savings for part 121 operators by allowing more options
for equipping and restocking FAK on their aircraft and by eliminating
the need to petition for an exemption from regulatory requirements in
Appendix A to part 121. FAA would experience cost savings on the
processing of petitions for exemption from Appendix A.
Though part 121 operators would incur minimal costs to equip an EMK
with a few additional supplies, overall, the proposed rule would
maintain safety and result in net cost savings for both industry and
FAA by establishing more flexible EMK and FAK requirements.
II. Authority for This Rulemaking
FAA's authority to issue rules on aviation safety is found in title
49 of the United States Code (49 U.S.C.). Subtitle I, section 106,
describes the authority of the FAA Administrator. Subtitle VII,
Aviation Programs, describes in more detail the scope of the agency's
authority.
FAA is issuing this notice of proposed rulemaking under the
authority described in 49 U.S.C. 106(f), which establishes the
authority of the Administrator to promulgate regulations and rules, and
49 U.S.C. 44701(a)(5), which requires the Administrator to promote safe
flight of civil aircraft in air commerce by prescribing regulations and
setting minimum standards for cybersecurity and other practices,
methods, and procedures necessary for safety in air commerce and
national security. This rulemaking is within the scope of that
authority. Finally, this rulemaking implements the Congressional
mandate set forth in section 368 of the FAA Reauthorization Act of
2024. Section 368 requires FAA to issue a notice of proposed rulemaking
regarding FAK and EMK equipment and training for required flight
crewmembers, as provided in 14 CFR part 121.\5\
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\5\ Section 368 of Public Law 118-63, 138 Stat. 1136 (49 U.S.C.
44701 note).
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III. Background
A. 2024 FAA Reauthorization
1. Section 367 ``Sense of Congress Regarding Mandated Contents of
Onboard Emergency Medical Kits''
Section 367 of the 2024 FAA Reauthorization \6\ provided that it
was the sense of Congress that:
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\6\ Section 367 of Public Law 118-63, 138 Stat. 1136.
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(1) a regularly scheduled panel of experts should reexamine and
provide an updated list of mandated contents of onboard emergency
medical kits that is thorough and practical, keeping passenger safety
and well-being paramount; and
(2) such panel should consider including on the list of mandated
contents of such medical kits, at a minimum, opioid overdose reversal
medication.
In response to section 367 of the 2024 FAA Reauthorization, FAA's
Federal Air Surgeon asked the Aerospace Medical Association (ASMA) to
provide scientific and practical advice for revising current EMK
requirements.
[[Page 50498]]
2. Section 368 ``Passenger Aircraft First Aid and Emergency Medical Kit
Equipment and Training'' of the 2024 FAA Reauthorization
Section 368(a) of the 2024 FAA Reauthorization required FAA to
issue a notice of proposed rulemaking regarding first aid and emergency
medical kit equipment and training required for flight crewmembers as
provided in 14 CFR part 121, no later than 2 years after the date of
the Act's enactment.\7\ Specifically, in carrying out subsection (a) of
section 368, subsection (b) directed FAA to consider the following:
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\7\ Section 368 of Public Law 118-63, 138 Stat. 1136 (49 U.S.C.
44701 note).
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(1) the benefits and costs (including the costs of flight
diversions and emergency landings) of requiring any new medications or
equipment necessary to be included in approved emergency medical kits;
(2) whether the contents of the emergency medical kits include, at
a minimum, appropriate medications and equipment that can practicably
be administered to address--
(A) the emergency medical needs of children and pregnant women;
(B) opioid overdose reversal;
(C) anaphylaxis; and
(D) cardiac arrest;
(3) what contents of the emergency medical kits should be readily
available, to the extent practicable, for use by flight crews without
prior approval by a medical professional.\8\
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\8\ Id.
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FAA considered subsection (b)(1) of Section 368 and supported this
directive in section V.A. (Regulatory Notices and Analyses, Regulatory
Impact Analysis) of this preamble. FAA considered subsection (b)(2) and
the medications and equipment listed therein using a proposal by AsMA,
with further discussion of AsMA's report in section III.C of this
preamble. With AsMA's report (referred to hereinafter as the AsMA
report) and FAA's independent analysis of section 368(b)(2)(A) through
(D), FAA concluded that appropriate medications and medical equipment
should be made available for use on transport aircraft for the medical
conditions and events as considered by Congress. Therefore, FAA
proposes in this rulemaking for operators to equip their aircraft with
an EMK that includes adequate supplies for medical personnel to provide
basic evaluation and initial treatment for medical conditions and
events described in section 368 and other life-threatening conditions
as proposed in Sec. 121.807. FAA considered section 368(b)(3) and
discusses access and contents of EMK in sections IV.A.1. (Appendix A to
part 121, Emergency Medical Kit) and IV.B. (Flight Crewmember Training)
of this preamble. Finally, FAA is aware of the agency's obligation as
discussed in section 368(c) that FAA ``not later than 5 years after the
issuance of the final rule under subsection (a) and every 5 years
thereafter'' take action as appropriate to evaluate and revise ``(1)
the first aid and emergency medical kit equipment and training required
for flight crewmembers; and any required training for flight
crewmembers regarding the content, location, and function of such
kit.''
B. History
1. EMK, FAK, and Crewmember Training History
A FAK is a kit that contains supplies to provide necessary care for
injuries such as abrasions, lacerations, sprains or strains, and
fractures. An EMK contains supplies to address more serious conditions.
FAK were first introduced on commercial airliners in 1949, and EMK were
first introduced in 1986.\9\ The most recent revision to the EMK or FAK
in Appendix A occurred over 20 years ago.\10\ When each of these pieces
of emergency medical equipment was introduced, FAA set the requirement
for the kits to contain certain medical equipment and supplies approved
by the Administrator as suitable and sufficient for the type of
operation involved. This revision, titled ``Emergency Medical
Equipment'' (hereinafter the ``2001 Final Rule''), updated EMK and FAK
by establishing the current prescriptive list of each kit's \11\
contents. Though the 2001 EMK contents are dated by today's standards,
the list of contents was relatively modern when introduced. The 2001
revision required 64 different items from updated medication and
medical equipment lists--double the number (32) required
previously.\12\
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\9\ See generally Part 42-Irregular Air Carriers and Off-Route
Rules, 14 FR 7034 (Nov. 22, 1949); Emergency Medical Equipment, 51
FR 1218 (Jan. 9, 1986).
\10\ See Emergency Medical Equipment, 66 FR 19028 (Apr. 12,
2001).
\11\ Id. at 19044.
\12\ Appendix A to 14 CFR 121 (2000).
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Unlike the prescriptive kit content requirements, the 2001 final
rule did not mandate a ``one-size-fits-all'' requirement for crewmember
training utilizing an EMK and FAK. FAA asserted that requiring such a
training scheme would be overly burdensome and contrary to the efforts
made by operators who already were responsible for training crewmembers
on medical emergencies.\13\ However, some standardization for
crewmember training for in-flight medical events was implemented with
the publication of subpart X of part 121 on April 12, 2001.\14\
Training requirements outlined in Sec. 121.805, Crewmember training
for in-flight medical events, apply to all crewmembers, with additional
automated external defibrillator (AED) and cardiopulmonary
resuscitation (CPR) performance drill training requirements for flight
attendants.
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\13\ See Emergency Medical Equipment, 66 FR 19028 at 19036.
\14\ Id.
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2. Exemptions History
As previously mentioned, FAA issues exemptions on a temporary basis
to mitigate the negative externalities of relevant medication
shortages. The prescriptive nature of the current Appendix A to part
121 requires an exemption for every modification to a medication
listed. An exemption is required to substitute a medication, change a
dosage amount, or both.
For example, in 2013, FAA granted exemptions to Airlines for
America (A4A), National Air Carrier Association, Regional Airlines
Association, Sierra Pacific Airline, Inc., Virgin America Inc., and
Mesa Airlines, Inc. from Sec. 121.803(c)(3) and Appendix A to part 121
because of a Dextrose shortage in the market. These exemptions allowed
the subject air carriers to not stock Dextrose in their EMK. Operators
were required to inform employees, crewmembers, and other relevant
parties of the lack of Dextrose in the EMK, and the operators'
crewmembers were required to maintain a physical copy of the exemption
on each flight during which the exemption was used. This exemption was
for one year and was extended by two years by exemption number 10721A.
FAA considered the petitioners' request and supporting information and
found that a grant of exemption would be in the public interest for
three reasons: (1) an EMK is considered a ``no-go'' item, and the small
risk of a lack of an infrequently used EMK input (Dextrose) is
outweighed by the benefit of grounding fewer planes; (2) Dextrose
substitutions, while available, would be complex to administer and
potentially lead to human error and less operational efficiency; and
(3) given the nationwide shortage of Dextrose at the time, FAA
determined that it was not in the public interest for EMK suppliers to
be competing for Dextrose with the greater need and demand of ground-
based medical providers.
[[Page 50499]]
If this proposed rule were in place, then A4A could have found a
replacement for Dextrose, such as Glucagon, if such an option were
appropriate and available on the open market without requesting an FAA
exemption.
Many medications in the EMK can be pervasively unavailable, which
requires ongoing petitions for exemption. The process of reviewing the
efficacy of potentially dozens of exemptions is a resource-intensive
process for FAA. Several FAA offices meticulously review exemptions to
ensure the petition for an exemption, if granted, would meet regulatory
requirements in 14 CFR part 11 and safety thresholds. This process
requires resources from both FAA and the petitioners, who are
responsible for preparing and submitting the required exemption
paperwork. For example, FAA granted exemption number 10690 in 2013 in
response to a shortage of Atropine. Since 2013, FAA has extended this
exemption 11 times and expanded the exemption to include Atropine,
Dextrose, Epinephrine, or Lidocaine or all four medications if the
market fails to produce enough of each medication.
C. 2025 Aerospace Medical Association Report
In response to section 367 of the 2024 FAA Reauthorization,\15\
FAA's Federal Air Surgeon asked the Aerospace Medical Association to
provide scientific and practical advice for revising current EMK
requirements. FAA wanted to hear from Aerospace Medicine experts and
practitioners familiar with existing requirements who would be able to
make educated, scientifically based recommendations for improving FAA
EMK. In October 2024 AsMA convened a working group to develop
recommendations based on clearly identified (1) conditions, or
categories of conditions, that are reasonable to expect trained cabin
crew members to be able to address effectively with the contents of an
EMK or FAK; (2) contents, or categories of contents, necessary to
include to address these conditions; and (3) specific examples of
contents that would be sufficient to address each condition identified.
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\15\ Section 367 of Public Law 118-63, 138 Stat. 1136.
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FAA received the AsMA report on April 30, 2025. AsMA expanded the
scope of FAA's original request from solely providing a recommendation
on the contents for EMK to also include recommended revisions to the
contents of the FAK and Universal Precautions Kits (UPK) as well.\16\
As such, the AsMA report provided recommendations to revise each kit to
modern standards.
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\16\ For purposes of this rulemaking document, FAA uses the
abbreviation ``UPK'' to refer to both the singular and plural of
universal precaution kits. FAA considers the two respective terms to
be synonymous.
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AsMA developed this report with the intent that the report would
serve as a model for updating the list of medication contents and
dosages and the equipment required in a part 121 FAK and EMK. FAA
concluded a more flexible regulation to replace Appendix A would be
appropriate to avoid unnecessary exemptions for medication and
equipment substitutions while maintaining an equivalent level of
safety.\17\
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\17\ DeVoll J.P., Alves P., and Lyng J., FAA Onboard Medical
Kits Working Group Report (May 1, 2025). FAA placed a copy of the
AsMA report in the docket for this NPRM.
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IV. Discussion of the Proposal
A. Appendix A to Part 121
Currently, Appendix A to part 121 contains a prescriptive list of
medications and equipment for FAK and EMK along with a requirement that
at least one approved AED be on board. Appendix A currently requires
only one EMK and one AED for all operators operating under part 121. In
contrast, Appendix A requires operators to adjust the number of FAK
depending on the number of passenger seats.\18\
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\18\ See Appendix A to 14 CFR 121 (2025).
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1. Emergency Medical Kit
FAA currently requires an EMK to contain the following specific
items and quantities: one Sphygmomanometer; one Stethoscope; three
sizes of cricopharyngeal \19\ airways; four syringes of sizes necessary
to administer the required medications; six needles of the sizes
necessary to administer required medications; one 50 percent dextrose
injection, 50 cc; two epinephrine 1:1,000, single dose ampule or
equivalent; two diphenhydramine HC1 injection, single dose ampule or
equivalent; ten nitroglycerin tablets; one set of basic instructions
for the use of the medications in the kit; and one pair of protective
nonpermeable gloves or equivalent.\20\
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\19\ The term ``cricopharyngeal'' is spelled incorrectly in the
current regulation.
\20\ Appendix A to 14 CFR 121 (2025).
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The purpose of the EMK is to provide basic evaluation and initial
treatment for a passenger experiencing moderate to severe injuries and
illnesses until the aircraft can land and the passenger can be
transferred to emergency medical personnel. The contents of the EMK
include medicines and a wider range of medical equipment than in the
FAK. FAA intends for any person providing care using the contents of
the EMK to be a person with medical training. Furthermore, a crewmember
would only provide medical care using the contents of the EMK with
supervision from ground-based medical oversight.
FAA proposes to remove and reserve Appendix A to part 121 and
replace the current prescriptive list of items in Appendix A with
proposed Sec. 121.807. This new section would allow operators to
determine the items and amounts of those items that should be included
in an EMK to treat a list of life-threatening conditions operators may
encounter during a flight.
Specifically, FAA proposes operators equip their EMK with
sufficient resources to detect and treat, at a minimum, the nine life-
threatening medical conditions discussed further in the following
paragraphs. In accordance with section 368(b)(2)(B) of the 2024 FAA
Reauthorization, FAA has considered the specific signs and symptoms and
possible treatment options for opioid overdose. Further, in accordance
with section 368(b)(2)(A), FAA has considered the specific needs of
children and pregnant women when discussing signs and symptoms and
possible treatment options.
First, FAA recommends sufficient resources for chest pain and
cardiac emergencies, such as cardiac arrest, heart attack, unstable
angina, or arrhythmia which may include the following signs and
symptoms: loss of consciousness; chest pain or discomfort; shortness of
breath; rapid or irregular pulse; pain radiating to the arm, jaw, neck,
or back; dizziness, lightheadedness, or sweating. Treatment options
could include medication such as Aspirin.
Second, FAA recommends sufficient resources for airway or breathing
emergencies, which may include the following signs and symptoms:
shortness of breath, wheezing, coughing, chest tightness, difficulty
speaking, or blue skin. Treatment options could include medication such
as an inhaled short-acting bronchodilator.
Third, FAA recommends sufficient resources for sudden impairment of
consciousness, such as a seizure, which may include the following signs
and symptoms: loss or impairment of consciousness or confusion.
Treatment options could include antiepileptic medication.
Fourth, FAA recommends sufficient resources for major bleeding
(hemorrhage), which may include the following signs and symptoms:
visible
[[Page 50500]]
blood loss, rapid heart rate or breathing or both, pale or clammy skin,
weakness, dizziness, confusion, disorientation, or loss of
consciousness. Treatment options could include equipment such as a
commercial windlass-style tourniquet.
Fifth, FAA recommends sufficient resources for opioid overdose,
which may include the following signs and symptoms: slow or shallow
breathing, small pupils, altered mental status, blue skin or lips, or
unresponsiveness. Treatment options could include medication such as
naloxone.
Sixth, FAA recommends sufficient resources for hypoglycemia, which
may include the following signs and symptoms: altered mental status,
shakiness, sweating, clammy skin, nausea or vomiting, rapid heart rate
or breathing or both, or loss of consciousness. Treatment options could
include medication such as a dextrose-containing intravenous (IV)
solution.
Seventh, FAA recommends sufficient resources for gastrointestinal
(stomach) emergencies, which may include the following signs and
symptoms: dehydration from severe vomiting or diarrhea. Treatment
options could include medication such as an isotonic crystalloid IV
solution and antiemetics.
Eighth, FAA recommends sufficient resources for anaphylaxis
(sudden/acute severe allergic reaction), which may include the
following signs and symptoms: hives; swelling of the mouth, throat, or
tongue; difficulty breathing, rapid or weak pulse, dizziness; stomach
pain; nausea or vomiting; or loss of consciousness. Treatment options
could include medication such as epinephrine.
Finally, FAA recommends sufficient resources for childbirth, which
may include the following signs and symptoms: contractions, water
breaking, vaginal discharge, back pain, or pelvic pressure. Treatment
options could include equipment such as a delivery kit.
FAA relied on the AsMA report to formulate this list of life-
threatening conditions. Specifically, FAA determined the list of life-
threatening conditions AsMA's recommended list of medications and
equipment were intended to treat. FAA also considered the situations in
section 368 of the 2024 FAA Reauthorization that Congress asked FAA to
consider when proposing rulemaking regarding FAK and EMK. After
consideration of all sources, FAA concluded this proposed list of life-
threatening conditions was the most appropriate list for treatment by
modern EMK.\21\
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\21\ Sec. 368 of Public Law 118-63, 138 Stat. 1136 (49 U.S.C.
44701 note).
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In this NPRM, FAA seeks to address a long-standing need to provide
clear, risk-based requirements to operators for equipping and training
sufficiently to enable effective response to medical emergencies
onboard commercial aircraft. FAA believes the equipment identified in
existing Appendix A is too specific to be practical and cannot be
updated timely in response to changing standards of medical practice
and product availability. The prescriptive nature of Appendix A results
in unnecessary stakeholder and agency workload to submit and respond to
petitions for exemption when medications are not available. If
finalized as proposed, operators would utilize their Safety Management
System (SMS) to ensure the content of the FAK and EMK would be
monitored and adjusted, when necessary, based on the scope of their
operation, emergency medical event data, and advances in medical
science.\22\
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\22\ SMS includes systematic procedures, practices, and policies
for the management of safety risk. All part 121, 135 and 91.147
operators must have an SMS that meets the requirements of 14 CFR
part 5. The SMS is approved and surveilled by FAA to ensure
compliance. The operator implements medical event risk controls
(policies, procedures, and training) through the safety risk
management (SRM) processes required by part 5 (14 CFR 5.71). The
safety assurance component of SMS (14 CFR 5.53) requires monitoring
and measuring safety performance of operational processes and
continuously improving the level of safety performance. Strong
safety assurance processes will yield information used to maintain
the integrity of risk controls. The operator monitors the operation
and collects and analyzes data from medical events to validate the
risk controls are effective. If the risk controls are not effective
or the operator identifies a need for a new risk control, then the
operator triggers the SRM process to change the ineffective risk
control or develop the new risk control. This whole process is data
driven and monitored by FAA through continued operational
surveillance.
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To assist operators in developing their EMK, procedures, and
training, FAA has revised the current Advisory Circular (AC) 121-33 to
include a model list of medications and equipment. AC 121-33C would
replace 121-33B \23\ and InFO 20001 \24\ and would establish one way,
but not the only way, for a part 121 operator to comply with the
proposed requirements for each FAK and EMK. Furthermore, FAA intends to
combine AC 120-44A \25\ and 121-34B \26\ into revised AC 120-44B to
consolidate flight crewmember training content appropriately. A draft
of these ACs has been placed in the docket for this rulemaking for
public comment.
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\23\ AC 121-33B--Emergency Medical Equipment, <a href="https://www.faa.gov/regulations_policies/advisory_circulars/index.cfm/go/document.information/documentID/22516">https://www.faa.gov/regulations_policies/advisory_circulars/index.cfm/go/document.information/documentID/22516</a>.
\24\ InFO20001: Emergency Medical Equipment on Passenger
Aircraft, <a href="https://www.faa.gov/sites/faa.gov/files/other_visit/aviation_industry/airline_operators/airline_safety/InFO20001.pdf">https://www.faa.gov/sites/faa.gov/files/other_visit/aviation_industry/airline_operators/airline_safety/InFO20001.pdf</a>.
\25\ AC Air Carrier First Aid Programs, <a href="https://www.faa.gov/documentLibrary/media/Advisory_Circular/ac120-44a.pdf">https://www.faa.gov/documentLibrary/media/Advisory_Circular/ac120-44a.pdf</a>.
\26\ AC Emergency Medical Equipment Training, <a href="https://www.faa.gov/documentLibrary/media/Advisory_Circular/AC121-34B.pdf">https://www.faa.gov/documentLibrary/media/Advisory_Circular/AC121-34B.pdf</a>.
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FAA proposes this revision because, as previously mentioned, FAA
seeks to promote modern medical practices by allowing assemblers of
kits to follow the most up-to-date medical advice and make changes as
necessary when designing the contents of each kit to treat the life-
threatening conditions proposed in Sec. 121.807. FAA also seeks to end
the practice of processing and granting exemptions to operators when
there are medication shortages in the market affecting the availability
of EMK contents.
FAA believes given the volume of requests for exemptions to
Appendix A, a rulemaking action would be appropriate to increase
flexibility to air carriers' EMK.
2. First Aid Kit
The current requirement for a FAK is the following: sixteen
adhesive bandage compresses, 1-inch; twenty antiseptic swabs; ten
ammonia inhalants; eight bandage compresses, 4-inch; five triangular
bandage compresses, 40-inch; one arm splint, noninflatable; one leg
splint, noninflatable; four roller bandage, 4-inch; two adhesive tape,
1-inch standard roll; and one bandage scissors.\27\
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\27\ Appendix A to 14 CFR 121 (2025).
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The purpose of the FAK is to provide necessary care for injuries
such as abrasions, lacerations, sprains or strains, and fractures.
Crewmembers are already trained by their part 121 operators to assist
with such injuries but are not required to be equivalent to the expert
level of proficiency attained by professional emergency medical
personnel.
As previously mentioned, FAA proposes to remove and reserve
Appendix A to part 121 and replace the current prescriptive-based
regulation in Appendix A with a new Sec. 121.807. This new section
would maintain the current requirement for the number of FAK equipped
onboard the aircraft to increase as the number of passenger seats
increase.\28\ Each operator would
[[Page 50501]]
have the flexibility to design their own FAK and any ancillary
equipment; however, each operator would ensure their FAK contents were
sufficient to provide adequate medical supplies to address injuries
such as abrasions, lacerations, sprains or strains, and fractures.
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\28\ FAA intends to maintain the current requirement found in
Appendix A of one FAK for 0-50 passenger seats, two FAK for 51-150
passenger seats, three FAK for 151-250 passenger seats, and four FAK
for more than 250 passenger seats.
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Though AsMA recommended operators include medications in their FAK,
FAA declines to pursue that recommendation but intends to encourage
those same medications to be included in an EMK. FAK currently in use
in part 121 operations do not contain any medications. Adding a
medication to those kits would require altering crewmember training and
adding unnecessary complexity to the FAK because crewmembers are
already aware and have the understanding that medications are found in
an EMK rather than a FAK; therefore, requiring new medications in a FAK
would only add unnecessary complication for crewmembers using a FAK.
FAA believes it is appropriate to incorporate additional medications in
an EMK if additional medications are required.
3. Universal Precaution Kit
FAA is not proposing UPK requirements in this proposed rulemaking.
FAA does not currently regulate UPK; however, AsMA recommended and
proposed a model UPK. The purpose of the UPK is to provide Occupational
Safety and Health Administration (OSHA)-compliant Personal Protective
Equipment (PPE) for crewmembers and on-board volunteer medical
responders. The AsMA report recommended UPK include nitrile gloves,
sanitizer, absorbent pads, and other necessary PPE for mitigating
bodily fluids until the aircraft lands and additional resources are
available.
FAA encourages operators to create and maintain their own suite of
UPK but declines to propose a regulation requiring it to be onboard
aircraft. FAA would provide guidance in its draft Advisory Circular on
how an operator might design a UPK if they choose to stock such a kit.
The draft Advisory Circular has been placed in the docket for this
rulemaking.
4. Emergency Medical Equipment and Automated External Defibrillators
(Sec. Sec. 121.803, 121.805)
Currently, Sec. 121.803, titled Emergency medical equipment,
contains the requirement that passenger-carrying airplanes must be
equipped with approved FAK and EMK, and AEDs. Though Appendix A to part
121 lists specific contents for each kit, Sec. 121.803 contains the
regulatory requirement that each passenger-carrying airplane equip each
kit. Specifically, Sec. 121.803(c) references Appendix A when
describing the contents of both kits. Section 121.803(c)(3) also
references emergency medical kits as modified as of April 12, 2004.
FAA proposes to make a conforming amendment to Sec. 121.803(c) to
strike the reference to Appendix A and replace it with a reference to
Sec. 121.807. FAA finds this action is necessary to remove and reserve
Appendix A as part of this rulemaking while still referencing the new,
appropriate section in part 121 for each kit's contents. FAA also
proposes to remove Sec. 121.803(c)(3) because the reference to an
``approved emergency medical kit as modified effective April 12, 2004''
is no longer relevant given operators would no longer carry EMK more
than 20 years old.
In addition, part 121 regulations pertaining to AEDs on aircraft
are located in Appendix A. Given FAA does not intend to remove any
requirements for AEDs, FAA proposes to redesignate and update this
regulatory requirement in Sec. 121.803(c)(3). FAA also proposes to
remove the current reference to ``April 30, 2005'' in the removed
Appendix A because FAA finds that operators would no longer equip their
AEDs with power sources more than 20 years old. FAA finds it is
necessary to redesignate this regulatory requirement because FAA
proposes to remove and reserve Appendix A. In doing so, FAA does not
seek to remove or otherwise modify the manner and means of compliance
for operators regarding their AEDs. FAA seeks to maintain the same AED
requirements that part 121 operators have followed for decades.
Furthermore, the current reference to AEDs is outdated. The current
regulations in Sec. Sec. 121.803(c)(3) and 121.805(b)(1) contain
references to 21-year-old EMK that operators no longer use or would be
approved to use today. Thus, FAA proposes to relocate the current AED
requirements found in Appendix A to Sec. 121.803(c)(3), and FAA
proposes to remove references to ``April 12, 2004'' and associated
language from Sec. Sec. 121.803 and 121.805.
B. Crewmember Training
Section 368(a) of the 2024 FAA Reauthorization also directed the
NPRM to address training required for flight crewmembers. FAA has
considered if changes to required crewmember training are necessary and
has concluded the regulations do not require changes at this time.
Currently, Sec. 121.801 establishes that certificate holders or
their agents are not required to provide medical care or establish a
standard of care; rather, Sec. 121.805 requires each training program
to provide instruction as appropriate for each crewmember. Air carriers
are currently responsible for instructional training of crewmembers on
the location, function, and intended operation of emergency medical
equipment and the associated emergency medical event procedures, in
accordance with Sec. 121.805(b)(1) and (2). In addition, crewmembers
must receive instruction to familiarize them with the content of the
EMK, in accordance with Sec. 121.805(b)(3). Familiarization with the
content of EMK is appropriate because requiring crewmembers to be
skilled in administering the contents of EMK, without medical advice,
would require crewmembers to be given medical training. There is no
need to change these requirements as part of this rulemaking because
the current requirements are flexible enough to accommodate the changes
in this proposed rule that would allow operators to change the content
of their kits. The current requirements would continue to require
crewmembers to be familiar with the content of those changing kits.
Therefore, FAA will not take further action to revise crewmember
training regulations.
[[Page 50502]]
C. Crewmember Training for In-Flight Medical Events (Sec. 121.805)
Section 121.805 establishes standards for crewmember training
concerning the location, function and operation of emergency medical
equipment, and the contents of EMK. Though Appendix A is not
specifically mentioned in this section, Sec. 121.805(b)(4) provides
instruction to familiarize crewmembers with the content of EMK as
modified on April 12, 2004. FAA proposes to remove Sec. 121.805(b)(4)
because this reference is no longer relevant given operators operating
today would not be using pre-April 12, 2004, medical kits, and Sec.
121.805(b)(3) already requires crewmember training to include
instruction to familiarize crewmembers with the content of EMK.
Therefore, FAA does not believe there is a need to reference pre- and
post-April 2004 EMK.
V. Regulatory Notices and Analyses
A. Regulatory Impact Analysis
Executive Order (E.O.) 12866 (``Regulatory Planning and Review'')
and E.O. 13563 (``Improving Regulation and Regulatory Review'') require
agencies to regulate in the ``most cost-effective manner,'' to make a
``reasoned determination that the benefits of the intended regulation
justify its costs,'' and to develop regulations that ``impose the least
burden on society.'' FAA has determined this proposed rule is not a
significant regulatory action as defined in section (3)(f) of E.O.
12866.
E.O. 14192 (``Unleashing Prosperity through Deregulation''), issued
January 31, 2025, instructs agencies to ``alleviate unnecessary
regulatory burdens.'' FAA expects this proposed rule, if finalized as
proposed, to be an E.O. 14192 deregulatory action.
In conducting this analysis, FAA has determined this proposed rule
has benefits that justify its costs. This section provides FAA's
analysis of the regulatory impact of the proposed rule.
1. Baseline for Analysis
The existing regulatory framework and practices for equipping a
part 121 operator's EMK and FAK constitute the baseline for this
analysis. The impacted entities of the proposed rule include all air
carriers operating under part 121. FAA uses a 6-year period for this
analysis. A 6-year period of analysis encompasses the typical time
between granting, amending, and extending new precedent-setting
Appendix A exemptions. A 6-year analysis period also encompasses the
life span of a typical FAK.\29\
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\29\ Is Your First Aid Kit Expired?, American Red Cross (Jun.
17, 2024), <a href="https://www.redcross.org/take-a-class/resources/articles/do-first-aid-kits-expire?srsltid=AfmBOoqnQY86Y1jjz70Z1vFYWGxINry9AMsYJ3QM1qg40-zP0Xsqij2m">https://www.redcross.org/take-a-class/resources/articles/do-first-aid-kits-expire?srsltid=AfmBOoqnQY86Y1jjz70Z1vFYWGxINry9AMsYJ3QM1qg40-zP0Xsqij2m</a>.
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Currently, part 121 operators must have one to four approved FAK
based on the number of passenger seats on the aircraft and one approved
EMK per aircraft. Each approved kit must contain the medications and
medical equipment specified in Appendix A to 14 CFR part 121. In
addition to stocking medical kits with the contents required under
Appendix A, several operators, including Southwest, United, Alaska,
Delta, American,\30\ and Frontier Airlines,\31\ have voluntarily
equipped their EMK with medications to treat medication overdoses. This
economic analysis assesses the incremental costs and benefits of the
proposed rule against these existing regulatory requirements and
practices.
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\30\ Southwest Airlines to Carry Naloxone or ``Narcan'' on
Planes Following Pettersen Push, Office of U.S. Representative
Brittany Pettersen (February 1, 2024), <a href="https://pettersen.house.gov/news/documentsingle.aspx?DocumentID=566">https://pettersen.house.gov/news/documentsingle.aspx?DocumentID=566</a>.
\31\ Carvalho, Anna-Maria, and Vincent Poirier, Naloxone is
becoming more available in airline medical kits, CMAJ (2018),
<a href="https://pmc.ncbi.nlm.nih.gov/articles/PMC6019339/">https://pmc.ncbi.nlm.nih.gov/articles/PMC6019339/</a>.
\32\ FAA Aerospace Forecast Fiscal Years 2025-2045 (2025),
<a href="https://www.faa.gov/data_research/aviation/aerospace_forecasts/FY-2025-2045-Full-Forecast-Document-and-Tables.pdf">https://www.faa.gov/data_research/aviation/aerospace_forecasts/FY-2025-2045-Full-Forecast-Document-and-Tables.pdf</a>, page 103.
\33\ The existing requirements for the number of FAK on part 121
aircraft are: 1 FAK for aircraft with less than 50 passenger seats;
2 FAK for aircraft with 51 to 150 passenger seats; 3 FAK for
aircraft with 151 to 250 passenger seats; and 4 FAK for aircraft
with more than 250 passenger seats. FAA estimated the number of FAK
on part 121 aircraft based upon the number of certified passenger
seats on all part 121 aircraft. 14 CFR 121, Appendix A (2025).
---------------------------------------------------------------------------
This proposed rule impacts the EMK and FAK on all aircraft
conducting part 121 operations. FAA estimates that, in the base year of
this analysis, the active affected fleet would include 7,063 active
aircraft. Using an assumed annual growth rate of 1.7 percent,\32\ FAA
estimates the affected population would increase to 7,684 active
aircraft throughout the analysis period. Each active aircraft must have
one EMK, but the number of FAK required on a part 121 aircraft depends
upon the number of passenger seats on the aircraft.\33\ FAA estimates
there would be 17,807 FAK on the 7,063 active aircraft in the base year
of the analysis, and FAA assumes the number of FAK would grow at the
same rate as the number of active aircraft (1.7%). Table 1 displays the
number of affected aircraft, FAK, and EMK throughout the period of
analysis.
Table 1--Estimated Affected Aircraft, FAK, and EMK
----------------------------------------------------------------------------------------------------------------
Active
Year aircraft Total FAK Total EMK
----------------------------------------------------------------------------------------------------------------
0............................................................... 7,063 17,807 7,063
1............................................................... 7,183 18,110 7,183
2............................................................... 7,306 18,418 7,306
3............................................................... 7,430 18,731 7,430
4............................................................... 7,556 19,049 7,556
5............................................................... 7,684 19,373 7,684
----------------------------------------------------------------------------------------------------------------
Source: FAA data as of June 2024.
2. Benefits
This rule proposes removing the list of required items in EMK and
FAK and replacing those lists with a list of medical events those kits
must be able to treat, thereby providing greater flexibility to
operators to design their own kits based on current availability of
contents. This proposed rule would ensure contents are practical and
sufficient to allow crewmembers to address the most common emergency
illnesses or injuries that occur onboard commercial aircraft. The
proposed rule is necessary to replace prescriptive language within the
existing regulation that cannot be kept current with new flexible
requirements that address clearly defined risks.
Ideally, the quantification of the potential safety benefits for
this proposed regulation would involve a three-step process. FAA would
(1) estimate the baseline's expected value of risk; (2) estimate how
effectively the proposed rule would mitigate this risk;
[[Page 50503]]
and (3) multiply the estimates in steps one and two. However, FAA could
not quantify the potential safety benefits of the proposed rule because
step two relies on data that is not currently available.
Expected Value of Risk for the Baseline
Quantifying the expected value of risk for the baseline is a three-
step process. First, FAA identified what could go wrong in the absence
of the proposed rule. Outcomes include in-flight medical emergencies,
hospitalizations,\34\ deaths, and diversions.\35\ Second, FAA uses
probabilities of what could go wrong through the relative frequency
approach.\36\ Based upon a 2013 study of over 7 million flights, the
New England Journal of Medicine estimated the likelihood of an in-
flight medical emergency (0.1664%), a hospitalization (0.043%), a death
(0.0005%), and a diversion (0.0123%) on a given flight.\37\ Third, FAA
quantified the expected value of risk \38\ for the baseline using the
DOT's Value of Statistical Life (VSL) of $13.7 million \39\ and a
weighted average cost of a diversion of approximately $132,000.\40\
Table 2 displays the expected value of risk for the baseline.
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\34\ Whether or not the passenger was admitted to a hospital.
\35\ Whether or not the aircraft was diverted from its intended
destination.
\36\ The probability of any outcome is roughly equal to the
proportion of times it comes up over a long history of repetitions.
\37\ Peterson et al., Outcomes of Medical Emergencies on
Commercial Airline Flights, The New England Journal of Medicine (May
30, 2013), <a href="https://www.nejm.org/doi/10.1056/NEJMoa1212052">https://www.nejm.org/doi/10.1056/NEJMoa1212052</a>.
\38\ The expected value of risk is an operation that essentially
multiplies the cost consequences of each event by its probability of
occurrence and sums all these products over the entire universe of
events.
\39\ Departmental Guidance on Valuation of a Statistical Life in
Economic Analysis, U.S. Department of Transportation (2025), <a href="https://www.transportation.gov/office-policy/transportation-policy/revised-departmental-guidance-on-valuation-of-a-statistical-life-in-economic-analysis">https://www.transportation.gov/office-policy/transportation-policy/revised-departmental-guidance-on-valuation-of-a-statistical-life-in-economic-analysis</a>.
\40\ The cost of a diversion is dependent on several factors,
including aircraft size. A 2023 Transportation Research Board
research paper estimated that the cost of a diversion ranged from
$25,000 for narrow-body aircraft to $100,000 for widebody aircraft.
See Managing a Flight Diversion with an Emergency Response at Small,
Non-Hub, or General Aviation Airports, National Academies of
Sciences, Engineering, and Medicine (2023), <a href="https://nap.nationalacademies.org/catalog/26900">https://nap.nationalacademies.org/catalog/26900</a>). FAA used a weighted
average cost of a flight diversion based upon the share of domestic
operations in widebody and narrowbody aircraft and then converted
this weighted average to 2024 dollars. See Transtats, Bureau of
Transportation Statistics (2025), <a href="https://www.transtats.bts.gov/Fields.asp?gnoyr_VQ=GED">https://www.transtats.bts.gov/Fields.asp?gnoyr_VQ=GED</a>).
Table 2--Expected Value of Risk for the Baseline
--------------------------------------------------------------------------------------------------------------------------------------------------------
In-flight Event frequencies Cost of adverse outcomes ($M)
Year Departures \1\ medical ------------------------------------------------------------------------ Total costs
emergencies Hosp.\2\ Death Diversions Hosp.\2\ Death Diversions ($M)
--------------------------------------------------------------------------------------------------------------------------------------------------------
0............................... 8,593,688 14,304 3,596 43 1,058 $2,315 $589 $123 $3,083
1............................... 8,739,781 14,547 3,657 44 1,076 2,355 599 125 3,135
2............................... 8,888,357 14,794 3,764 44 1,094 2,423 609 127 3,189
3............................... 9,039,459 15,046 3,828 45 1,113 2,465 619 130 3,243
4............................... 9,193,130 15,302 3,893 46 1,132 2,507 630 132 3,298
5............................... 9,349,413 15,562 3,959 47 1,151 2,549 641 134 3,354
--------------------------------------------------------------------------------------------------------------------------------------------------------
\1\ FAA used the 2025-2045 FAA Aerospace Forecast's 2024 domestic departures estimation (8.2 million) with a 1.7% annual departures growth rate (<a href="https://www.faa.gov/data_research/aviation/aerospace_forecasts/FY-2025-2045-Full-Forecast-Document-and-Tables.pdf">https://www.faa.gov/data_research/aviation/aerospace_forecasts/FY-2025-2045-Full-Forecast-Document-and-Tables.pdf</a>).
\2\ The number of hospitalizations excludes fatalities.
\3\ USDOT's Maximum Abbreviated Injury Scale (MAIS) estimates the cost of non-lethal injuries based upon a fraction of the VSL, with a MAIS 1 injury
being a minor injury and a MAIS 5 being a critical injury. FAA assumes that all hospitalizations result in a MAIS 2 (moderate) injury, which is
estimated to be 4.7% as costly as a fatality ($643,900). (See: Departmental Guidance on Valuation of a Statistical Life in Economic Analysis, U.S. DOT
(2025), <a href="https://www.transportation.gov/office-policy/transportation-policy/revised-departmental-guidance-on-valuation-of-a-statistical-life-in-economic-analysis">https://www.transportation.gov/office-policy/transportation-policy/revised-departmental-guidance-on-valuation-of-a-statistical-life-in-economic-analysis</a>).
Effectiveness of the Proposed Rule at Mitigating the Baseline's Risk
Although FAA expects the proposed rule to reduce the risk of
adverse outcomes relative to the baseline, the Agency does not know the
extent of the reduction. Therefore, it was not possible for FAA to
quantify the potential safety benefits of this proposed rule. When a
proposed rule's effects cannot be quantified or monetized, OMB Circular
A-4 requires that FAA present any relevant quantitative information
along with a description of unquantified effects.\41\ In the following
paragraphs, FAA describes why the Agency expects the proposed rule to
result in a risk reduction relative to the baseline.
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\41\ OMB Circular A-4, (2003), page 28. <a href="https://obamawhitehouse.archives.gov/omb/circulars_a004_a-4">https://obamawhitehouse.archives.gov/omb/circulars_a004_a-4</a>.
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This rule would revise the list of required items in EMK and FAK to
ensure contents are up to date, practical, and sufficient to allow
crewmembers to address the most common emergency illnesses or accidents
that occur onboard commercial aircraft. Having current and appropriate
medical supplies onboard aircraft would thus lower risk to the
passengers, airline staff, and operators by allowing for effective
treatment of life-threatening emergencies aboard aircraft. Lowered risk
would likely lead to lower rates of patient morbidity, mortality, and
possibly fewer aircraft diversions.
Furthermore, changing the regulatory requirement from a list of
items to a list of conditions creates flexibility for operators to use
their SMS to reduce medication and equipment or increase medication and
equipment based on the emergency medical events the operator encounters
or trending aviation medical event data or both. For example, small
operators conducting short flights in small aircraft might have
different medical event risks than large operators conducting long
flights in larger aircraft. The operators monitor medical event data
through their SMS and can revise the kit to address the new or
increased risk in their operation.
3. Cost Savings
First Aid Kit
FAA finds that affected operators would experience cost savings
from the proposed rule's flexible FAK requirements. FAA assumes that
purchasing a new FAK would cost approximately 15 percent less due to
the proposed rule's flexibilities.\42\ FAA requests comment on this
assumption. According to a 2024 article by the American Red Cross, most
FAK supplies have a shelf life of 5 years.\43\ Therefore, FAA assumes a
FAK needs to be fully replaced every five years, or alternatively, 20
percent of all FAK must be replaced annually. A standard
[[Page 50504]]
part 121 FAK available for purchase from medical supplier Cabin Crew
Safety costs $192.50.\44\ Based upon the cost savings and kit
replacement schedule, FAA estimates that affected operators would save
approximately $28.88 every 5 years for each new FAK purchased. Using
cost and population projections, FAA estimates that part 121 operators
would save $643,943 ($545,557 at a seven percent discount rate and
$597,966 at a three percent discount rate) on FAK throughout the period
of analysis. Table 3 displays the FAK population and cost savings over
the analysis period.
---------------------------------------------------------------------------
\42\ FAA estimated the cost savings from the FAK recommended,
but not required, by the draft Advisory Circular by comparing the
cost of each item in the existing FAK to the costs of items in a new
FAK, which would comply with the proposed rule's flexible
requirements.
\43\ Is Your First Aid Kit Expired?, American Red Cross (June
17, 2024), <a href="https://www.redcross.org/take-a-class/resources/articles/do-first-aid-kits-expire?srsltid=AfmBOoo_yuYk-rMlMKZxceGppcYP1siQpC5C97i2EOTIog2yQoYE8-DZ">https://www.redcross.org/take-a-class/resources/articles/do-first-aid-kits-expire?srsltid=AfmBOoo_yuYk-rMlMKZxceGppcYP1siQpC5C97i2EOTIog2yQoYE8-DZ</a>.
\44\ Aircraft First Aid Kit Standard, Cabin Crew Safety (2025),
<a href="https://www.cabincrewsafety.aero//stock/cabin/199/aircraft-first-aid-kit-standard.html">https://www.cabincrewsafety.aero//stock/cabin/199/aircraft-first-aid-kit-standard.html</a>.
Table 3--Cost Savings From Symptoms-Based FAK
----------------------------------------------------------------------------------------------------------------
New or
Year Total FAK replaced FAK Per-unit FAK Total FAK
\1\ savings savings \2\
----------------------------------------------------------------------------------------------------------------
0............................................... 17,807 3,561 $28.88 $102,842
1............................................... 18,110 3,622 28.88 104,603
2............................................... 18,418 3,684 28.88 106,382
3............................................... 18,731 3,746 28.88 108,190
4............................................... 19,049 3,810 28.88 110,027
5............................................... 19,373 3,875 28.88 111,898
----------------------------------------------------------------------------------------------------------------
\1\ Assuming 20% of FAK are replaced annually, the number of FAK replaced equals 20% of total FAK in a given
year. For example, the number of new or replaced FAK in year 0 is calculated as follows: 3,561 = 20% * 17,807.
\2\ Total FAK savings equals the number of new or replaced FAK times the per-unit FAK savings.
Appendix A Exemptions
The proposed rule would eliminate the need for exemptions from EMK
and FAK contents requirements because of medication shortages. This
would save both FAA and affected entities exemption application and
processing costs. To estimate petition for exemption and processing
costs, FAA separates exemptions into precedent-setting exemptions,
extensions, and amendments.\45\ Precedent-setting exemptions incur a
greater cost to FAA and industry than non-precedent setting extensions
and amendments. FAA assumes amendments and extensions incur the same
time and cost burdens, whereas precedent-setting exemptions incur a
much greater burden on FAA and industry.\46\ Based upon internal
estimates of processing time and costs,\47\ FAA assumes precedent-
setting exemptions cost FAA $2,272 per petition for exemption, whereas
amendments and extensions cost FAA $901 per petition for exemption.
Table 4 shows the total unit cost of precedent setting and non-
precedent setting exemptions.
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\45\ Precedent-setting exemptions are exemptions that would
provide relief from a section of 14 CFR for which relief has not
been provided in the past or that would provide relief under a new
factual situation. An extension may be granted when a petitioner
states, and FAA agrees, that the conditions and reasons in the
original petition and exemption remain unchanged. A petitioner may
also request an amendment to its exemption, such as adding aircraft,
changing a name, adding a part, or changing a condition or
limitation. Most Appendix A precedent-setting exemptions have been
initial petitions, and most extensions and amendments have been non-
precedent setting. Though precedent-setting exemptions can also be
amendments or extensions, in this analysis, FAA assumes all
amendments and extensions in the period of analysis are not
precedent-setting. Oftentimes, air carrier trade associations file
petitions on behalf of their organization and member airlines. When
this occurs, each air carrier wishing to exercise the relief
provided in a particular grant of exemption must submit a letter of
intent to FAA, and FAA must process this letter of intent. In this
analysis, FAA assumes no costs to submit or process a letter of
intent.
\46\ Petitions to amend or extend exemptions are often requested
in tandem by a petitioner. For this analysis, FAA assumes the cost
burden of an exemption extension/amendment equals the cost and time
burden of individual extensions and amendments.
\47\ FAA employees from four offices (the Office of Rulemaking,
the Office of the Chief Counsel, the Office of Aerospace Medicine,
and the Flight Standards Service) process Appendix A exemptions. FAA
estimated the labor hours for each role within each office and
estimated those labor costs using each role's fully loaded hourly
wage. An FAA employee's fully loaded wage is the hourly wage of each
employee (assuming an employee works 2,080 hours annually)
multiplied by the Federal Government's fringe benefit factor. A
fringe benefit factor estimates the additional monetary benefits an
employee receives beyond their salary, including insurance and
retirement benefits. The Federal Government's fringe benefit rate is
36.25 percent (a fringe benefit factor of 1.3625). See OMB Memo M-
08-13 (March 11, 2008).
Table 4--Per-Unit FAA Exemption Processing Costs
----------------------------------------------------------------------------------------------------------------
Amendments and Precedent setting
Fully loaded extensions -----------------------
FAA office/role Annual salary hourly wage ------------------------
\1\ \2\ Labor Labor Labor cost
hours Labor cost hours
----------------------------------------------------------------------------------------------------------------
Petitions Analyst............... $67,847 $44.44 1.5 $67 3 $133
Petitions Manager............... 165,891 108.67 0.5 54 1 109
Attorney........................ 141,125 92.44 0 0 3 277
Flight Standards Administrative. 60,489 39.62 2 79 2 79
Flight Standards Analyst........ 114,298 74.87 5 374 18 1,348
Flight Standards Manager........ 165,891 108.67 3 326 3 326
-------------------------------------------------------------------------------
Per-Unit Exemption .............. .............. .......... 901 .......... 2,272
Processing Cost............
----------------------------------------------------------------------------------------------------------------
\1\ Source: 2024 Core Compensation Plan (FV) Salary Table, Rest of U.S. Locality (See: Pay and Benefit, FAA
(2025), <a href="https://www.faa.gov/jobs/working_here/benefits">https://www.faa.gov/jobs/working_here/benefits</a>).
\2\ The fully loaded wage is estimated using a fringe benefit of 36.25% (See: OMB Memo M-08-13 (March 11, 2008))
and an estimated 2,080 hours worked annually. For example, the fully loaded hourly wage of a rulemaking
analyst is calculated as follows: $50.85 = ($77,631 * 1.3625)/2,080.
[[Page 50505]]
FAA assumes that, for a petitioner to submit an Appendix A petition
for exemption, an administrative assistant prepares the Appendix A
petition, and an executive-level employee reviews the petition. For
amendments and extensions, FAA assumes an administrative assistant
spends 1 hour drafting a petition and an operations manager spends 0.25
hours reviewing the petition. For precedent-setting petitions, FAA
assumes administrative assistants spend 1.5 hours drafting a petition
and an operations manager spends 0.5 hours reviewing the petition.
Using Bureau of Labor Statistics salary estimations, FAA assumes the
unitary application cost for a petitioner ranges between $57 and $97.
FAA requests comment on the Appendix A application labor and cost
assumptions. Table 5 displays the unitary application cost for
precedent setting and non-precedent setting petitions.
Table 5--Per-Unit Industry Petition for Exemption Cost
----------------------------------------------------------------------------------------------------------------
Amendments and Precedent setting
Fully loaded extensions -----------------------
Industry role Annual salary hourly wage ------------------------
\1\ \2\ Labor Labor Labor cost
hours Labor cost hours
----------------------------------------------------------------------------------------------------------------
Administrative Assistant........ $54,060 $33.66 1 $34 1.5 $50
Operations Manager.............. 150,080 93.44 0.25 23 0.5 47
-------------------------------------------------------------------------------
Per-Unit Petition .............. .............. .......... 57 .......... 97
Application Cost...........
----------------------------------------------------------------------------------------------------------------
\1\ FAA uses the Bureau of Labor Statistics (BLS) mean annual wage for Office and Administrative Support
Occupations to estimate the salary of an Administrative Assistant and General and Operations Managers for an
Operations Managers within the Air Transportation industry (See: Occupational Employment and Wage Statistics
Query System, BLS (May 2024), <a href="https://data.bls.gov/oes">https://data.bls.gov/oes</a>).
\2\ The fully loaded wage is estimated using a fringe benefit of 29.5% (See: Employer Cost for Employee
Compensation--December 2024, BLS (2024), <a href="https://www.bls.gov/news.release/archives/ecec_03142025.pdf">https://www.bls.gov/news.release/archives/ecec_03142025.pdf</a>) and an
estimated 2,080 hours worked annually. For example, the fully loaded hourly wage of an administrative
assistant is calculated as follows: $33.66 = ($54,060 * 1.295)/2,080.
FAA estimated the number of precedent setting and non-precedent
setting exemptions based on the number of exemptions from 2016 to 2025.
From 2016 to 2025, there were two precedent-setting exemptions, four
extensions, and 10 amendments.\48\ Based upon this historical data, FAA
made the following assumptions for Appendix A petitions for exemption:
(1) there would be one new precedent-setting exemption during the
analysis period that would be extended biennially; (2) two existing
precedent-setting exemptions (10690 and 18955) would exist throughout
the period of analysis, and the two active 10690 and one active 18995
exemptions would continue to be extended biennially; and (3) all three
exemptions would have amendments granted biennially. Table 6 displays
the projected number of precedent setting and non-precedent setting
exemptions processed throughout the period of analysis. FAA estimates
there would be one precedent-setting exemption, 11 extensions, and nine
amendments.
---------------------------------------------------------------------------
\48\ Exemption No. 10690 from 2013, granted airlines represented
by Airlines for America (A4A), the National Air Carrier Association
(NACA), and the Regional Airline Association (RAA) to operate
without meeting the Appendix A requirements for Atropine. Between
2016 and 2025, FAA granted seven amendments and three extensions to
Exemption No. 10690, including an amendment (10690E) which expanded
the exempted requirements to include Atropine, Dextrose,
Epinephrine, and Lidocaine. See FAA Exemption No. 10690E,
<a href="http://Regulations.gov">Regulations.gov</a> (2016), <a href="https://www.regulations.gov/document/FAA-2013-0034-0015">https://www.regulations.gov/document/FAA-2013-0034-0015</a>). Exemption No. 18995 from 2022 granted airlines
represented by A4A, NACA, and RAA to operate without meeting the
Appendix A requirements for ammonia inhalants. Between 2022 and
2025, FAA granted one extension and one amendment to Exemption No.
18995. See: FAA Exemption No. 18995, <a href="http://Regulations.gov">Regulations.gov</a> (2022), <a href="https://www.regulations.gov/document/FAA-2021-0706-0001">https://www.regulations.gov/document/FAA-2021-0706-0001</a>).
Table 6--Projected Number of Exemptions in the Absence of the Proposed Rule
----------------------------------------------------------------------------------------------------------------
Year
Exemption name/type -----------------------------------------------------------------------
0 1 2 3 4 5
----------------------------------------------------------------------------------------------------------------
10690 Exemptions
----------------------------------------------------------------------------------------------------------------
Non-Precedent Setting: 1 2 1 2 1 2
Extensions.......................... .......... 2 .......... 2 .......... 2
Amendments.......................... 1 .......... 1 .......... 1 ..........
----------------------------------------------------------------------------------------------------------------
18995 Exemptions
----------------------------------------------------------------------------------------------------------------
Non-Precedent Setting: 1 1 1 1 1 1
Extensions.......................... .......... 1 .......... 1 .......... 1
Amendments.......................... 1 .......... 1 .......... 1 ..........
----------------------------------------------------------------------------------------------------------------
Projected New Exemption
----------------------------------------------------------------------------------------------------------------
Precedent Setting Exemption............. 1 0 0 0 0 0
Non-Precedent Setting: 0 1 1 1 1 1
Extensions.......................... .......... .......... 1 .......... 1 ..........
Amendments.......................... .......... 1 .......... 1 .......... 1
----------------------------------------------------------------------------------------------------------------
Using the estimated unitary costs and exemption projections, FAA
estimates that, in the absence of the proposed rule, the existing
Appendix A exemption process would cost $21,522 ($18,423 at a seven
percent discount rate and $20,074 at a three discount rate) over the
period of analysis. Table 7 displays the annual number of exemptions,
the costs of industry applications, and FAA's processing costs.
[[Page 50506]]
Table 7--Exemption Costs in the Absence of the Proposed Rule
--------------------------------------------------------------------------------------------------------------------------------------------------------
Total exemptions Industry petition costs FAA processing costs
-------------------------------------------------------------------------------------------------------- Total
Year Non- Non- costs
Precedent Non-precedent Precedent precedent Total cost Precedent precedent Total cost
--------------------------------------------------------------------------------------------------------------------------------------------------------
0................................... 1 2 $97 $114 $211 $2,272 $1,801 $4,073 $4,285
1................................... 0 4 0 228 228 0 3,602 3,602 3,830
2................................... 0 3 0 171 171 0 2,702 2,702 2,873
3................................... 0 4 0 228 228 0 3,602 3,602 3,830
4................................... 0 3 0 171 171 0 2,702 2,702 2,873
5................................... 0 4 0 228 228 0 3,602 3,602 3,830
--------------------------------------------------------------------------------------------------------------------------------------------------------
4. Unquantified Costs
FAA cannot quantify the proposed rule's impact on the costs of EMK
because FAA cannot quantify either the costs of new EMK requirements or
the cost savings from increased requirement flexibilities. When a
proposed rule's effects cannot be quantified or monetized, OMB Circular
A-4 requires FAA to present any relevant quantitative information along
with a description of unquantified effects.\49\ The proposed rule would
impose costs on affected operators to equip their EMK through
additional supplies, including supplies to treat opioid overdose,
childbirth, and supplies for treating children. Though this would
present an additional cost for operators, FAA cannot quantify the
magnitude of this cost. Further, five operators (Southwest, United,
Alaska, Delta, American, and Frontier Airlines) already equip EMK with
overdose medication and would not incur an additional cost from the
proposed rule's overdose medication requirement. The proposed rule
would also grant operators new flexibilities to reduce or replace other
medications and equipment, resulting in initial and recurrent EMK cost
savings. However, FAA cannot quantify the magnitude of the proposed
rule's initial and recurrent EMK cost savings.
---------------------------------------------------------------------------
\49\ OMB Circular A-4, (2003), page 28. <a href="https://obamawhitehouse.archives.gov/omb/circulars_a004_a-4">https://obamawhitehouse.archives.gov/omb/circulars_a004_a-4</a>.
---------------------------------------------------------------------------
Table 8 compares the proposed rule's flexible requirements with the
baseline EMK content requirements. FAA requests comment on the
unquantified impacts the proposed rule would have on EMK production.
Table 8--Comparison of Proposed Rule Conditions With Baseline EMK Contents
----------------------------------------------------------------------------------------------------------------
Baseline EMK contents [quantity] Proposed rule conditions
----------------------------------------------------------------------------------------------------------------
Stethoscope [1]........................................ Chest pain and cardiac emergencies such as cardiac
CPR mask (3 sizes), 1 pediatric, 1 small adult, 1 large arrest, heart attack, unstable angina, or arrhythmia.
adult, or equivalent.
Epinephrine 1:10,000, 2 cc, injectable, (single dose
ampule or equivalent) [2]
Atropine, 0.5 mg, 5 cc (single dose ampule or
equivalent) [2]
Aspirin tablets, 325 mg [4]
Lidocaine, 5 cc, 20 mg/ml, injectable (single dose
ampule or equivalent) [2]
Nitroglycerin tablets, 0.4 mg [10]
Self-inflating manual resuscitation device with 3 masks Airway or breathing emergencies, such as asthma attack.
(1 pediatric, 1 small adult, 1 large adult or
equivalent).
Airways, oropharyngeal (3 sizes): 1 pediatric, 1 small
adult, 1 large adult or equivalent
Bronchodilator, inhaled (metered dose inhaler or
equivalent) [1]
Sphygmomanometer [1]................................... Sudden impairment of consciousness, such as seizure.
Tourniquet (IV Admin Set) [1].......................... Sudden onset of major bleeding (hemorrhage).
No baseline content requirements: Opioid overdose.
Dextrose, 50%/50 cc injectable (single dose ampule Hypoglycemia.
or equivalent) [1].
IV Admin Set (Tubing w/2 Y connectors; Alcohol Gastrointestinal (stomach) emergencies.
sponges [2]; Adhesive tape, 1-inch standard roll
adhesive; Tape scissors; Tourniquet).
Saline solution, 500 cc [1]
Needles (2-18 ga., 2-20 ga., 2-22 ga., or sizes
necessary to administer required medications).
Syringes (1-5 cc, 2-10 cc, or sizes necessary to
administer required medications)
Antihistamine tablets, 25 mg [4]................... Anaphylaxis (sudden/acute severe allergic reaction).
Antihistamine injectable, 50 mg, (single dose
ampule or equivalent) [2]
Epinephrine 1:1000, 1 cc, injectable, (single dose
ampule or equivalent) [2]
No baseline content requirements: Childbirth.
Pairs of Protective nonpermeable gloves or Medications and equipment not paired.
equivalent.
[[Page 50507]]
Analgesic, non-narcotic, tablets, 325 mg [4]
Basic instructions for use of the drugs in the kit.
----------------------------------------------------------------------------------------------------------------
5. Summary
The proposed rule may reduce the risk of various negative outcomes
that occur during part 121 operations, including in-flight emergencies,
hospitalizations, deaths, and aircraft diversions. In addition, part
121 operators and FAA would experience cost savings. Part 121 operators
would save on the costs to equip and restock FAK on their aircraft and
would save the costs associated with petitioning for an Appendix A
exemption. FAA would experience cost savings on the processing of
petitions for exemptions from Appendix A. Over the period of analysis,
FAA estimates the proposed rule would save industry and FAA $665,476
($563,992 at a seven percent discount rate and $618,051 at a three
percent discount rate) on FAK. Part 121 operators would incur minimal
costs to equip EMK with a few additional supplies. Overall, the
proposed rule would maintain safety and result in net cost savings for
both industry and FAA by creating more flexible EMK and FAK
requirements. Table 9 provides a summary of the qualitative benefits
and costs and the quantified cost savings to both part 121 operators
and FAA.
Table 9--Summary of Costs
[Millions 2024$]
----------------------------------------------------------------------------------------------------------------
----------------------------------------------------------------------------------------------------------------
Qualitative Benefits
----------------------------------------------------------------------------------------------------------------
<bullet> Reduced probability of medical emergencies during part 121 operations, including in-flight medical
emergencies, hospitalizations, deaths, and diversions.
<bullet> Faster adoption of modern medications and equipment to best address medical emergencies in future part
121 operations.
----------------------------------------------------------------------------------------------------------------
Qualitative Costs
----------------------------------------------------------------------------------------------------------------
<bullet> Costs for affected operators to equip an EMK with additional supplies to treat opioid overdose,
childbirth, and supplies for treating children.
<bullet> Cost savings for affected operators through new flexibilities to reduce or replace other medications
and equipment within EMK.
----------------------------------------------------------------------------------------------------------------
Cost Savings ($M)
----------------------------------------------------------------------------------------------------------------
2024$ 7% 3% 7% 3%
----------------------------------------------------------------------------------------------------------------
Present value
Annualized
----------------------------------------------------------------------------------------------------------------
FAK Cost Savings
----------------------------------------------------------------------------------------------------------------
Total (Part 121 Operators)...... $0.644 $0.546 $0.598 $0.114 $0.110
----------------------------------------------------------------------------------------------------------------
Exemption Cost Savings
----------------------------------------------------------------------------------------------------------------
Total Cost Savings: 0.022 0.018 0.020 0.004 0.004
Part 121 Operators.......... 0.001 0.001 0.001 0.000 0.000
FAA......................... 0.020 0.017 0.019 0.004 0.003
----------------------------------------------------------------------------------------------------------------
Total Cost Savings
----------------------------------------------------------------------------------------------------------------
Total Cost Savings: 0.665 0.564 0.618 0.118 0.114
Part 121 Operators.......... 0.645 0.547 0.599 0.115 0.111
FAA......................... 0.020 0.017 0.019 0.004 0.003
----------------------------------------------------------------------------------------------------------------
[[Page 50508]]
B. Regulatory Flexibility Act
The Regulatory Flexibility Act (RFA) of 1980 (5 U.S.C. 601-612), as
amended by the Small Business Regulatory Enforcement Fairness Act of
1996 (Pub. L. 104-121) and the Small Business Jobs Act of 2010 (Pub. L.
111-240), requires Federal agencies to consider the effects of the
regulatory action on small business and other small entities and to
minimize any significant economic impact. The term ``small entities''
comprises small businesses and not-for-profit organizations
independently owned and operated and are not dominant in their fields,
and governmental jurisdictions with populations of less than 50,000.
FAA used the definition of small entities in the RFA for this
analysis. The RFA defines small entities as small businesses, small
governmental jurisdictions, or small organizations. In 5 U.S.C. 601(3),
the RFA defines ``small business'' to have the same meaning as ``small
business concern'' under section 3 of the Small Business Act. The Small
Business Act authorizes the Small Business Administration (SBA) to
define ``small business'' by issuing regulations. SBA (2023) has
established size standards for various types of economic activities, or
industries, under the North American Industry Classification System
(NAICS). These size standards generally define small businesses based
on the number of employees or annual receipts.
SBA classifies a scheduled passenger air carrier as a small entity
if that scheduled passenger operator has 1,500 or fewer employees.\50\
To identify small entities, FAA identified the primary operator and
used Bureau of Transportation Statistics (BTS) data to determine
whether the operator meets the applicable size standard. Of the 38
passenger-carrying part 121 operators, FAA estimates 17 operators have
1,500 or fewer employees and are classified as small entities.\51\
Therefore, FAA has determined this proposed rule will have an impact on
a substantial number of small entities.
---------------------------------------------------------------------------
\50\ 13 CFR 121.201.
\51\ FAA used BTS' September 2025 airline employment data to
estimate the number of small and large part 121 passenger-carrying
operators (See: Airline Employment Data by Month, BTS (September
2025), <a href="https://www.transtats.bts.gov/Employment/">https://www.transtats.bts.gov/Employment/</a>). FAA assumes all
operators who did not meet BTS's size standard for employment
reporting are small businesses.
---------------------------------------------------------------------------
However, FAA has determined the proposed rule would not have a
significant economic impact on a substantial number of small part 121
operators for the following reasons: The proposed rule would impose
minimal costs on small entities to equip their EMK through additional
supplies, including supplies to treat opioid overdose, childbirth, and
supplies for treating children. Overall, the proposed rule would result
in cost savings from the proposed new flexible EMK and FAK
requirements, which would also eliminate the need for exemption from
Appendix A.
Therefore, FAA certifies the proposed rulemaking would not result
in a significant economic impact on a substantial number of small
entities. FAA solicits comments regarding this determination.
C. International Trade Impact Assessment
The Trade Agreements Act of 1979 (Pub. L. 96-39), as amended by the
Uruguay Round Agreements Act (Pub. L. 103-465), prohibits Federal
agencies from establishing standards or engaging in related activities
that create unnecessary obstacles to the foreign commerce of the United
States. Pursuant to these Acts, the establishment of standards is not
considered an unnecessary obstacle to the foreign commerce of the
United States, so long as the standard has a legitimate domestic
objective, such as the protection of safety, and does not operate in a
manner that excludes imports that meet this objective. The statute also
requires consideration of international standards and, where
appropriate, that they be the basis for U.S. standards.
FAA has assessed the potential effect of this proposed rule and
determined it ensures the safety of the American public and does not
exclude imports that meet this objective. As a result, FAA does not
consider this proposed rule as creating an unnecessary obstacle to
foreign commerce.
D. Unfunded Mandates Assessment
The Unfunded Mandates Reform Act of 1995 (2 U.S.C. 1531-1538)
governs the issuance of Federal regulations that require unfunded
mandates. An unfunded mandate is a regulation that requires a State,
local, or Tribal Government or the private sector to incur direct costs
without the Federal Government having first provided the funds to pay
those costs. FAA determined the proposed rule would not result in the
expenditure of $187,000,000 or more ($100,000,000 adjusted for
inflation using the most current Implicit Price Deflator for the Gross
Domestic Product) by State, local, or Tribal Governments, in the
aggregate, or the private sector, in any one year.
E. Paperwork Reduction Act
The Paperwork Reduction Act of 1995 (44 U.S.C. 3507(d)) requires
FAA to consider the impact of paperwork and other information
collection burdens imposed on the public. FAA has determined there
would be no new requirement for information collection associated with
this proposed rule.
F. International Compatibility
In keeping with U.S. obligations under the Convention on
International Civil Aviation, it is FAA policy to conform to
International Civil Aviation Organization (ICAO) Standards and
Recommended Practices to the maximum extent practicable. ICAO Annex 6,
6.2.2 (a) states, ``An aeroplane shall be equipped with accessible and
adequate medical supplies.'' As a recommendation, it further states,
``Medical supplies should comprise: (1) one or more first-aid kits for
the use of cabin crew in managing incidents of ill health; and (2) for
aeroplanes required to carry cabin crew as part of the operating crew,
one universal precaution kit (two for aeroplanes authorized to carry
more than 250 passengers) for the use of cabin crew members in managing
incidents of ill health associated with a case of suspected
communicable disease, or in the case of illness involving contact with
body fluids; and (3) for aeroplanes authorized to carry more than 100
passengers, on a sector length of more than two hours, a medical kit,
for the use of medical doctors or other qualified persons in treating
in-flight medical emergencies.'' Attachment A to Annex 6 provides
guidance on the ``types, number, location, and contents of the medical
supplies.'' If finalized as proposed, this rule would harmonize with
ICAO Annex 6, section 6.2.2 (a) in whole, since prescriptive
requirements for the contents of on-board medical kits will be removed.
[[Page 50509]]
G. Environmental Analysis
FAA has analyzed the environmental impacts of this proposed rule
pursuant to the National Environmental Policy Act of 1969 (NEPA) (42
U.S.C. 4321 et seq.). FAA has determined this rule is categorically
excluded pursuant to Paragraph B-2.6(f) of Appendix B to FAA Order
1050.1G, FAA National Environmental Policy Act Implementing
Procedures.\52\ Categorical exclusions are categories of actions the
agency has determined normally do not significantly affect the quality
of the human environment and therefore do not require either an
environmental assessment (EA) or environmental impact statement
(EIS).\53\ In analyzing the applicability of a categorical exclusion,
the agency must also consider whether extraordinary circumstances are
present that would warrant the preparation of an EA or EIS.\54\ This
rulemaking, which will provide additional flexibility to operators in
how they stock their EMK, is categorically excluded pursuant to
Paragraph B-2.6(f) of FAA Order 1050.1G: ``Regulations, standards, and
exemptions.'' FAA does not anticipate any environmental impacts, and
there are no extraordinary circumstances present in connection with
this rulemaking.
---------------------------------------------------------------------------
\52\ 90 FR 29615 (Jul. 3, 2025).
\53\ See DOT Order 5610.1D Sec. 9.
\54\ Id. Sec. 9(b).
---------------------------------------------------------------------------
VI. Executive Order Determinations
A. Executive Order 13132, Federalism
FAA has analyzed this proposed rule under the principles and
criteria of E.O. 13132, Federalism. FAA has determined this action
would not have a substantial direct effect on the States, or the
relationship between the Federal Government and the States, or on the
distribution of power and responsibilities among the various levels of
government, and, therefore, would not have federalism implications.
B. Executive Order 13211, Regulations That Significantly Affect Energy
Supply, Distribution, or Use
FAA analyzed this proposed rule under E.O. 13211, Actions
Concerning Regulations that Significantly Affect Energy Supply,
Distribution, or Use. FAA has determined it would not be a
``significant energy action'' under the E.O. and would not be likely to
have a significant adverse effect on the supply, distribution, or use
of energy.
C. Executive Order 13609, Promoting International Regulatory
Cooperation
E.O. 13609, Promoting International Regulatory Cooperation,
promotes international regulatory cooperation to meet shared challenges
involving health, safety, labor, security, environmental, and other
issues and to reduce, eliminate, or prevent unnecessary differences in
regulatory requirements. FAA has analyzed this action under the
policies and agency responsibilities of E.O. 13609 and has determined
this action would have no effect on international regulatory
cooperation.
D. Executive Order 14192, Unleashing Prosperity Through Deregulation
This proposed rule, if finalized as proposed, is expected to be an
E.O. 14192 deregulatory action.
VII. Additional Information
A. Comments Invited
FAA invites interested persons to participate in this rulemaking by
submitting written comments, data, or views. FAA also invites comments
relating to the economic, environmental, energy, or federalism impacts
that might result from adopting the proposals in this document. The
most helpful comments reference a specific portion of the proposal,
explain the reason for any recommended change, and include supporting
data. To ensure the docket does not contain duplicate comments,
commenters should submit only one time if comments are filed
electronically, or commenters should send only one copy of written
comments if comments are filed in writing.
FAA will file in the docket all comments it receives, as well as a
report summarizing each substantive public contact with FAA personnel
concerning this proposed rule. Before acting on this proposal, FAA will
consider all comments it receives on or before the closing date for
comments. FAA will consider comments filed after the comment period has
closed if it is possible to do so without incurring expense or delay.
FAA may change this proposal in light of the comments it receives.
Privacy: In accordance with 5 U.S.C. 553(c), FAA solicits comments
from the public to inform its rulemaking process better. FAA posts
these comments, without edit, including any personal information the
commenter provides, to <a href="http://www.regulations.gov">www.regulations.gov</a>, as described in the system
of records notice (DOT/ALL-14 FDMS), which can be reviewed at
<a href="http://www.dot.gov/privacy">www.dot.gov/privacy</a>.
B. Confidential Business Information
Confidential Business Information (CBI) is commercial or financial
information that is both customarily and actually treated as private by
its owner. Under the Freedom of Information Act (FOIA) (5 U.S.C. 552),
CBI is exempt from public disclosure. If your comments responsive to
this NPRM contain commercial or financial information that is
customarily treated as private, that you actually treat as private, and
that is relevant or responsive to this NPRM, it is important you
clearly designate the submitted comments as CBI. Please mark each page
of your submission containing CBI as ``PROPIN.'' FAA will treat such
marked submissions as confidential under the FOIA, and they will not be
placed in the public docket of this NPRM. Submissions containing CBI
should be sent to the person in the FOR FURTHER INFORMATION CONTACT
section of this document. Any commentary FAA receives that is not
specifically designated as CBI will be placed in the public docket for
this rulemaking.
[[Page 50510]]
C. Electronic Access and Filing
A copy of this NPRM, all comments received, any final rule, and all
background material may be viewed online at <a href="http://www.regulations.gov">www.regulations.gov</a> using
the docket number listed above. Electronic retrieval help and
guidelines are available on the website. It is available 24 hours each
day, 365 days each year. An electronic copy of this document may also
be downloaded from the Office of the Federal Register's website at
<a href="http://www.federalregister.gov">www.federalregister.gov</a> and the Government Publishing Office's website
at <a href="http://www.govinfo.gov">www.govinfo.gov</a>. A copy may also be found at FAA's Regulations and
Policies website at <a href="http://www.faa.gov/regulations_policies">www.faa.gov/regulations_policies</a>.
Copies may also be obtained by sending a request to the Federal
Aviation Administration, Office of Rulemaking, ARM-1, 800 Independence
Avenue SW, Washington, DC 20591, or by calling (202) 267-9677.
Commenters must identify the docket or notice number of this
rulemaking.
All documents FAA considered in developing this proposed rule,
including economic analyses and technical reports, may be accessed in
the electronic docket for this rulemaking.
D. Small Business Regulatory Enforcement Fairness Act
The Small Business Regulatory Enforcement Fairness Act (SBREFA) of
1996 requires FAA to comply with small entity requests for information
or advice about compliance with statutes and regulations within its
jurisdiction. A small entity with questions regarding this document may
contact its local FAA official or the person listed under the FOR
FURTHER INFORMATION CONTACT heading at the beginning of the preamble.
To find out more about SBREFA on the internet, visit <a href="http://www.faa.gov/regulations_policies/rulemaking/sbre_act/">www.faa.gov/regulations_policies/rulemaking/sbre_act/</a>.
List of Subjects in 14 CFR Part 121
Air carriers, Aircraft, Airmen, Aviation safety, Reporting and
recordkeeping requirements, Safety, Transportation.
The Proposed Amendment
For the reasons discussed in the preamble, the Federal Aviation
Administration proposes to amend chapter I of title 14, Code of Federal
Regulations, as follows:
PART 121--OPERATING REQUIREMENTS: DOMESTIC, FLAG, AND SUPPLEMENTAL
OPERATIONS
0
1. The authority citation for part 121 is revised to read as follows:
Authority: 49 U.S.C. 106(f), 40103, 40113, 40119, 41706, 42301
preceding note added by Pub. L. 112-95, sec. 412, 126 Stat. 89,
44101, 44701-44702, 44705, 44709-44711, 44713, 44716-44717, 44722,
44729, 44732; 46105; Pub. L. 111-216, 124 Stat. 2348 (49 U.S.C.
44701 note); Pub. L. 112-95, 126 Stat. 62 (49 U.S.C. 44732 note);
Pub. L. 115-254, 132 Stat. 3186 (49 U.S.C. 44701 note) sec. 368,
Pub. L. 118-63, 138 Stat. 1330 (49 U.S.C. 44703 note).
0
2. Amend Sec. 121.803 by:
0
a. Revising paragraph (c) introductory text,
0
b. removing paragraph (c)(3),
0
c. Redesignating paragraph (c)(4) as paragraph (c)(3), and revising
redesignated paragraph (c)(3).
The revisions read as follows:
Sec. 121.803 Emergency medical equipment.
* * * * *
(c) For treatment of injuries, medical events, or minor accidents
that might occur during flight time, each airplane must have the
following equipment that meets the specifications and requirements of
Sec. 121.807:
* * * * *
(3) In airplanes for which a flight attendant is required and with
a maximum payload capacity of more than 7,500 pounds, at least one
approved automated external defibrillator, legally marketed in the
United States in accordance with Food and Drug Administration
requirements, that must:
(i) Be stored in the passenger cabin.
(ii) Be maintained in accordance with the manufacturer's
specification.
(iii) Have a power source that meets FAA Technical Standard Order
requirements for power sources for electronic devices used in aviation
as approved by the Administrator.
Sec. 121.805 [Amended]
0
3. Amend Sec. 121.805 by removing paragraph (b)(4) and redesignating
paragraph (b)(5) as paragraph (b)(4).
0
4. Add Sec. 121.807 to read as follows:
Sec. 121.807 Performance requirements for emergency medical kits and
first aid kits.
(a) The following items must be readily accessible to the crew,
stored securely, and kept free from dust, moisture, and damaging
temperatures:
(1) The number of FAA-approved first-aid kits required in paragraph
(c) of this section;
(2) At least one emergency medical kit; and
(3) At least one automated external defibrillator complying with
Sec. 121.803 requirements.
(b) An aircraft must have a first aid kit(s) that is accessible to
crewmembers and provides adequate medical supplies that address
injuries. These injuries include abrasions, lacerations, sprains or
strains, and fractures.
(c) The minimum number of first aid kits required on an aircraft is
set forth in the following table:
------------------------------------------------------------------------
Number of
Number of passenger seats first-aid
kits
------------------------------------------------------------------------
0-50.................................................... 1
51-150.................................................. 2
151-250................................................. 3
More than 250........................................... 4
------------------------------------------------------------------------
(d) An aircraft must have an emergency medical kit that includes
adequate supplies for medical personnel to provide basic evaluation and
initial treatment for both adults and children with immediate life-
threatening medical conditions, as found in the table below:
Life-Threatening Conditions
(1) Chest pain and cardiac emergencies such as cardiac arrest,
heart attack, unstable angina, or arrhythmia
(2) Airway or breathing emergencies, such as asthma attack
(3) Sudden impairment of consciousness, such as seizure
(4) Major bleeding (hemorrhage)
(5) Opioid overdose
(6) Hypoglycemia
(7) Gastrointestinal (stomach) emergencies
(8) Anaphylaxis (sudden/acute severe allergic reaction)
(9) Childbirth
[[Page 50511]]
Appendix A to Part 121--First Aid Kits and Emergency Medical Kits
[Removed and Reserved]
0
5. Remove and reserve Appendix A to part 121.
Issued under authority provided by 49 U.S.C. 106(f), 44701, and
Sec. 368 of Public Law 118-63 in Washington, DC.
Susan Northrup,
Federal Air Surgeon, Office of Aerospace Medicine.
[FR Doc. 2026-15929 Filed 8-4-26; 8:45 am]
BILLING CODE 4910-13-P
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