Published in the Federal Register August 5, 2026 · 14 CFR Part 121 (Appendix A) · comment period 60 days
Quick Answers
What is being proposed?
The FAA proposes to replace the rigid, item-by-item emergency medical kit (EMK) and first aid kit (FAK) contents list in Appendix A to 14 CFR Part 121 with a more flexible, performance-based framework — while keeping the existing numbers of FAKs required per passenger-seating band (1 for 0–50 seats, 2 for 51–150, 3 for 151–250, 4 for 250+).
Why now?
Because of recurring drug shortages. Since 2015, the FAA has approved 14 exemptions (including for Spirit, Ameristar, and A4A/NACA/RAA carriers) to let airlines fly without every currently mandated item — atropine, dextrose, epinephrine, lidocaine, and ammonia inhalants among them. The NPRM is a policy response: update the standard instead of continuously exempting it.
What changes operationally?
Kit-content governance would move from a fixed Appendix A checklist toward operator-managed, SMS-based medical-event risk control — using the Part 5 SMS that Part 121 (and Part 135 / 91.147) operators already hold — supported by updated FAA guidance (draft Advisory Circular).
Is there a cost to airlines?
The FAA projects net cost savings for operators from flexible FAK requirements, and quantifies what a diverted flight really costs as the counterfactual: roughly $25,000 for a narrowbody diversion up to $100,000 for a widebody (2023 TRB research, converted to 2024 dollars).
Quick Compliance Summary
| Field | Detail |
|---|---|
| Regulatory body | Federal Aviation Administration (FAA) |
| Instrument | Notice of Proposed Rulemaking — Emergency Medical Equipment requirements in Appendix A to 14 CFR Part 121 |
| Status | Proposed — published August 5, 2026; comments due October 5, 2026 |
| Trigger | 14 FAA-approved exemptions since 2015 for EMK drug shortages (atropine, dextrose, epinephrine, lidocaine, ammonia inhalants) |
| Proposed approach | Performance-based, flexible kit contents managed through operator SMS (14 CFR Part 5) plus FAA guidance; FAK seat-band quantities maintained |
| Evidence base | FAA Onboard Medical Kits Working Group Report (May 1, 2025) — placed in the docket |
| Affected operators | Part 121 passenger carriers primarily; SMS rules referenced for Part 135 and 91.147 operators |
| Comment deadline | October 5, 2026 |
Who Should Read This
- Directors of Cabin Safety / Inflight Services — kit content policy, crew medical training alignment
- Safety Management / SMS managers — medical-event risk controls under Part 5 (5.71 SRM; 5.53 safety assurance)
- Procurement and supply-chain teams — the drug-shortage problem this NPRM responds to
- Flight Operations & dispatch — diversion economics and the medical-event decision framework
- Part 135 charter / air-ambulance providers — SMS interplay and future scope extension
- Airlines currently flying under EMK exemptions — Spirit, Ameristar, and the A4A/NACA/RAA letter-of-intent carriers
At a Glance
| Item | Detail |
|---|---|
| Regulatory anchor | Appendix A to 14 CFR Part 121 (emergency medical equipment) |
| FAK quantities (maintained) | 1 (0–50 seats) · 2 (51–150) · 3 (151–250) · 4 (250+) |
| EMK flexibility | Performance-based content decisions via SMS risk management |
| Exemptions history | 14 approved since 2015; Exemption No. 10690 (2013, atropine) and No. 18995 (2022, ammonia inhalants) are the precedents |
| Working group basis | FAA Onboard Medical Kits Working Group Report, May 1, 2025 |
| Diversion cost basis | $25,000 narrowbody – $100,000 widebody per diversion (TRB 2023, 2024 dollars) |
| Comment deadline | October 5, 2026 |
What This Does
Today, Appendix A to 14 CFR Part 121 prescribes a fixed list of EMK/FAK contents. The FAA’s own enforcement and exemption record shows that list is brittle: when a listed drug (atropine, dextrose, epinephrine, lidocaine, ammonia inhalants) goes into shortage, airlines cannot make the kit without the item and must petition for exemption — 14 times since 2015, involving dozens of carriers via A4A/NACA/RAA letters of intent.
The NPRM proposes to move the regulatory locus from “these exact items must be present” to “the operator must manage medical-event risk to an acceptable level, using SMS”. Under Part 5, operators already conduct safety risk management (SRM, §5.71) and safety assurance (§5.53); the proposal routes kit-content decisions through those processes, with FAA-approved guidance (a draft AC) defining recommended—but not mandated—kit contents. The FAK quantity bands stay as-is.
What it does NOT do
- It does not yet change any compliance obligations — this is an NPRM; the existing Appendix A requirements remain in force until a final rule is issued.
- It does not remove FAKs or reduce their mandated numbers.
- It does not transfer medical-guidance authority to airlines: operator decisions remain subject to FAA oversight through the approved SMS and surveillance.
- It does not apply to non-Part-121 operations beyond the SMS references for Part 135/91.147.
Why This Exists Now
- 2015–today: 14 FAA-approved exemptions responding to EMK item shortages (Spirit FAA-2025-0521/0522, Ameristar FAA-2017-0780, A4A/NACA/RAA FAA-2013-0034 and FAA-2021-0706 with 29 and 19 operators respectively, Vision Airlines, Aerodynamics Inc., and others).
- 2025: the FAA Onboard Medical Kits Working Group delivered its report (May 1, 2025), recommending modernization of kit contents to current medical standards.
- August 5, 2026: the FAA publishes this NPRM, pairing modernization with flexibility so the exemption machinery becomes unnecessary.
The economic driver is diversion cost. When a medical event forces a diversion, the tab is roughly $25,000 (narrowbody) to $100,000 (widebody) per event, per 2023 TRB research — a cost the FAA uses as the counterfactual to justify investment in kit efficacy.
Operational Impact Matrix
| Affected function | Action required | Deadline / driver | Reference |
|---|---|---|---|
| All Part 121 carriers | Submit comments on the NPRM (experience with exemptions is the most persuasive evidence) | Oct 5, 2026 | FR doc. 2026-15929 |
| SMS / safety departments | Assess SMP/SRM readiness to own medical-event risk controls (Part 5) | Pre-final-rule | 14 CFR 5.71 / 5.53 |
| Cabin safety / inflight | Draft internal kit-content standard aligned to the forthcoming draft AC | Pre-final-rule | Draft AC (in docket) |
| Procurement | Map current kit SKUs against shortage-prone items; model substitution scenarios | Ongoing | Exemption dockets |
| Part 135 / 91.147 | Confirm SMS scope and whether to comment on extension of flexibility | Oct 5, 2026 | NPRM scope |
| Medical training providers | Watch for crew-training implications of any new kit standard | With final rule | — |
Cost & Benefit
| Item | Amount |
|---|---|
| Diversion cost (2023 TRB, 2024 dollars) | ≈$25,000 narrowbody · ≈$100,000 widebody |
| FAK cost direction | Projected savings from flexible (AC-recommended, not mandated) FAK contents |
| Exemption-processing burden | Reduced: fewer petitions, letters of intent, and exemption amendments for airlines and FAA (four FAA offices involved per petition) |
What Operators Should Do Now
- Read the NPRM text and the Onboard Medical Kits Working Group Report in the docket before the comment deadline.
- Carriers with exemption history: document what worked and what didn’t — the FAA explicitly invites that lived experience.
- Draft pre-alignment of your SMS medical-event risk control narrative with the proposed performance-based approach.
- Model the impact of a flexible kit standard on crew training and emergency procedures manuals (EPMs).
Compliance Checklist
- NPRM assigned to an owner with a comment-submission calendar entry for Oct 5, 2026
- Current EMK/FAK configuration reconciled against Appendix A and any granted exemptions
- Inventory of shortage-prone items (atropine, dextrose, epinephrine, lidocaine, ammonia inhalants) maintained
- SMS medical-event risk-control mapping drafted (SRM + safety assurance evidence)
- Crew training/EPM impact assessment started
ARW take: the direction of travel is unmistakable — the FAA is replacing an equipment checklist with a risk-management system, following the same performance-based philosophy already applied to SMS and fatigue. The practical risk for operators is the transition gap: final-rule expectations for “acceptable” kit content will be defined by the draft AC, so procurement and training teams should treat the AC’s recommended list as a de facto standard the day it appears in the docket. Comment early — airlines that lived through 14 exemption cycles have the strongest evidence about which regulatory constructs work.
Key Dates
| Milestone | Date |
|---|---|
| First EMK shortage exemptions | 2015 onward (14 approved total) |
| FAA Onboard Medical Kits Working Group Report | May 1, 2025 |
| NPRM published | August 5, 2026 |
| Comments due | October 5, 2026 |
| Final rule (if pursued) | [CONFIRM: to be announced] |
Source Documents
- Federal Register — Improving Emergency Medical Kit Efficacy and Flexibility in Commercial Airline Operations (NPRM, August 5, 2026)
- FAA — Recently Published Rulemaking Documents (comment deadline October 5, 2026)
- TRB (2023) — Managing a Flight Diversion with an Emergency Response at Small, Non-Hub, or General Aviation Airports
- Exemption precedent — FAA Exemption No. 10690E (atropine etc.); Exemption No. 18995 (ammonia inhalants)
FAQ
Are my kits non-compliant today?
No. The current Appendix A rules remain in force until a final rule; the NPRM changes nothing yet.
What exactly stays the same?
FAK quantities by seating band, the requirement to carry EMKs, and FAA oversight of the outcome via SMS and surveillance.
How do I comment?
Via regulations.gov on docket FAA-2026-… (see the FR document) before October 5, 2026.
Will this help with drug shortages?
That is the intent: with performance-based governance, an operator can substitute for or manage a shortage through its SMS rather than petitioning for an exemption.
Related Reading
- FAA Radio Altimeter Final Rule — 5G Interference (ARW template reference article)
- https://aviationregwatch.com/faa-ad-2026-15-11-737-max-bear-strap-inspections/
- FAA Radio Altimeter Final Rule — 5G Interference (ARW template reference article)
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© 2026 Aviation Reg Watch. This article is an informational summary compiled from the sources listed above, not legal advice. Verify against the primary source before making compliance decisions.