Airline infant safety seat rule could cause more deaths than it prevents, pediatricians say

A proposed Federal Aviation Administration (FAA) regulation that would require infant restraint seats for children under age two would likely lead to more deaths in automobile crashes than the deaths prevented in air crashes, say pediatricians from the University of California, San Francisco and the University of Washington.

Current regulations allow children under two to ride free in a parent’s lap. With the new regulation, these children would need their own tickets for their own seats and seatbelts.  In a new analysis, researchers estimate that if the extra cost of buying airline tickets for the young children led only 5 to 10 percent of families to drive rather than fly, the projected increase in highway deaths would exceed the number of airplane crash deaths prevented.  This is because the possible number of deaths that could be prevented with airline safety seats is low—approximately four deaths in 10 years—because airplane travel is very safe, and because the majority of airplane crash deaths occur in crashes in which there are no survivors, according to the researchers.

Even when deaths caused by diversion to car travel are not counted, the estimated cost to save one infant’s life with an airline restraint seat was high.  If the average round-trip ticket cost $200, the cost would be $1.3 billion per life saved. “Many more lives could be saved by spending this money on other safety measures,” said UCSF pediatrician Thomas Newman, MD, MPH, lead author of the study.

The analysis was published in the October 14, 2003 issue of the journal Archives of Pediatric and Adolescent Medicine. Newman is Professor of Epidemiology and Biostatistics and Pediatrics at UCSF and a pediatrician at UCSF Children’s Hospital. His co-authors are Brian D. Johnston, MD, MPH, and David C. Grossman, MD, MPH of the Harborview Injury Prevention and Research Center and the Department of Pediatrics at the University of Washington, Seattle.

“The story of even a single young child dying in an airplane crash, whose death could have been prevented with a safety seat, makes all of us want to do something to keep such a tragedy from happening again,” Newman said. “Unfortunately, in this case these well-meaning efforts could backfire.”

The proposed FAA regulation has been urged by members of Congress and is among the top ten safety improvements urged by the National Transportation Safety Board, based on a few cases of unrestrained young children who might have survived crashes if restrained, as well as a sense that the number of people who might die in cars rather than planes because of the regulation could not be calculated because of uncertainty about how many would choose to drive.

Rather than making any assumptions about this number, Newman and his colleagues conducted their analysis to find the “break-even point”—how many families could switch to cars before the extra deaths from car travel exceeded those saved from plane crashes.  They used data from a variety of publicly available sources, including federal data on air and automobile safety.

They estimated the number of flights by young children each year—about 6.5 million—and the number of young children who might be passengers on survivable airplane crashes. They calculated the risk of death in an air crash if some of these infants rode in cars instead of on airlines.  The investigators assumed that parents would be cautious drivers taking their trips mostly on interstate highways—a scenario that should lead to about 70 percent fewer auto deaths per mile traveled than the national average.

Depending on the distance traveled, the researchers found that when more than 5 percent to 10 percent of the families with young children who would have traveled by air, instead were carried in cars, there would be more than four extra deaths from car crashes over the course of 10 years.  At that point, the FAA regulation would lead to more deaths than it prevented.

“We did not consider serious non-fatal injuries, but with this regulation, the statistics on those probably would look even worse,” Newman said.  “Serious nonfatal injuries are less common than deaths from air travel, but 80 times more common than deaths for car travel.  Thus virtually any substitution from air to car travel would increase serious injuries.” Other analyses, including one done by the FAA in 1995, have yielded similar results.

In an accompanying editorial in the journal, David Bishai, MD, PhD, of the Johns Hopkins School of Public Health, summarized the difficulty for policymakers dealing with the projected increase in car crash deaths.  “The infants who die in these car crashes do not crash and die statistically; they really crash—they really die… [But] the name and photo of the dead infant in the car crash will not haunt anybody in the world of aviation safety.”

Airlines could offer a solution that would allow parents and airline personnel to place children in child-restraint seats more often, without diverting parents and their children to car travel, Newman and his colleagues note.  In his editorial, Bishai praises this compromise, initially suggested by the FAA
—airlines could supply effective child-restraint seats and always seat infants’ parents next to vacant seats on sub capacity flights.  “Millions of infants could receive all of the protection of child-restraint systems and none of the costs with [this] policy,” Bishai wrote.