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PEDIATRICS Vol. 108 No. 5 November 2001, pp. 1218-1222
Occupant protection policies for children younger
than 2 years on aircraft are inconsistent with all other national
policies on safe transportation. Children younger than 2 years are not required to be restrained or secured on aircraft during takeoff, landing, and conditions of turbulence. They are permitted to be held on
the lap of an adult. Preventable injuries and deaths have occurred in
children younger than 2 years who were unrestrained in aircraft during
survivable crashes and conditions of turbulence. The American Academy
of Pediatrics recommends a mandatory federal requirement for restraint
use for children on aircraft. The Academy further recommends that
parents ensure that a seat is available for all children during
aircraft transport and follow current recommendations for restraint use
for all children. Physicians play a significant role in counseling
families, advocating for public policy mandates, and encouraging
technologic research that will improve protection of children in
aircraft.
ABSTRACT
Top
Abstract
Introduction
Background
Recommendation
References
Children younger than 2 years are the only occupants who,
under current federal regulation, are not required to be restrained or
secured on aircraft during takeoff, landing, and conditions of
turbulence; even items such as coffee pots must be secured. This
practice relating to nonrestraint of children on airplanes is
inconsistent with all occupant protection recommendations of the
American Academy of Pediatrics (AAP) in which priority has been placed
on safe transportation of children. Many child safety seats (CSSs) used
in motor vehicles are also approved for use on aircraft. The Federal
Aviation Administration (FAA) has stated that proper use of an approved
CSS for aircraft enhances child safety in the event of turbulence or a
crash, and the FAA informs parents that a "safety seat can be the
most important carry-on item of all."1 The FAA strongly
recommends but has not yet mandated that all children who fly,
regardless of age, should be restrained in the appropriate CSS for
their weight and size used in conjunction with the aircraft seat belt.
In a 1996 report to the President of the United States, the White House
Commission on Aviation Safety and Security stated that it is
inappropriate for infants to be afforded a lesser degree of protection
than that for older passengers.2 The Commission recommended that the FAA revise its regulations to require that all
occupants be restrained in aircraft during takeoff, landing, and
conditions of turbulence and that all infants and small children whose
weight is less than 40 lb and whose height is less than 40 in be
restrained in an aircraft-approved CSS. The Association of Flight
Attendants and the National Transportation Safety Board (NTSB) have
called for federal regulation requiring appropriate restraint
use.3-5 The NTSB has also called for the FAA to develop
standards for CSS use in aircraft. The FAA has argued that a mandatory
requirement for CSS use on aircraft will result in more injuries and
deaths to infants and toddlers because parents would not be willing to
buy a ticket to reserve a seat for the infant and would opt to travel
by car instead6; however, no data support this argument.
Children younger than 2 years are currently allowed to be held in
an adult's lap throughout a commercial aircraft flight, as stipulated
by the US Code of Federal Regulations (CFR).7 Alternatively, parents may choose to use a CSS certified under the
Federal Motor Vehicle Safety Standards and Regulations for travel in
aircraft and motor vehicles.8 Airlines are required to
accommodate the use of approved CSSs for young children with tickets;
however, the child must occupy a window seat in a nonexit row. Although
many airlines offer discounted rates for children younger than 2 years,
these rates are often not advertised, and parents must ask to receive a
reduced-rate ticket. If parents want to ensure that the child has a
passenger seat in which the CSS can be used, they must purchase a
ticket. If the child is held on the lap of an adult, no fare is charged
for the child. Children 2 years and older are required to sit in their
own passenger seat under the same regulations that apply to all other
passengers.
In 1995, in the aftermath of serious and sometimes unexpected events of
turbulence, the FAA issued a public advisory to airlines urging the use
of seat belts at all times when passengers are seated.6
Some airlines now comply, but the requirement does not apply to
children younger than 2 years because they are not required to be
restrained at any time during the flight.
Approximately 25 000 commercial flights depart from and arrive at
US airports daily.9 Although it is estimated that 4.6 million children younger than 2 years fly on US domestic airlines annually, inaccuracies in the passenger manifest, which contains the
names of all passengers as required by the US CFR, make it difficult to
obtain precise numbers. The NTSB has issued safety recommendations that
require standardized reporting of all passengers.10
The risk of death or serious injury in an aircraft is exceedingly
small. Using data from 1990 forward not controlled for age, the risk of
death was calculated at 1 in 8 million.11 During 1996, there were 319 passenger fatalities and 77 serious injuries on US air
carriers operating under the CFR. These data are not provided by year
of age of passenger but include all scheduled and nonscheduled services
on commercial and cargo carriers.12 Analysis of aircraft
crashes from 1976 through 1979 in which there were fatalities and
survivors revealed that unrestrained infant passengers had a relative
mortality risk of 5.9 (United States) and 9.6 (worldwide), compared
with restrained adult passengers. It could not be determined whether
the higher risk of mortality for infants was attributable to lack of
restraint use, fragility of infants, or both.13
In a study comparing persons fatally injured in aircraft in 1980 and
1990, blunt injury (in particular, head injury) from deceleration
forces was the most important threat to survival. Head injuries were
listed as the immediate cause of death in 33% of those younger than 15 years.14 As with other forms of transportation, effective
restraint systems decrease the probability of head injury.
Turbulence is the leading cause of nonfatal injuries to aircraft
passengers and flight attendants. From 1981 through 1997, there were
342 reports of turbulence affecting major airlines. Three passengers
died, 80 had serious injuries, and 769 had minor injuries.15
A child on the lap of an adult cannot be effectively restrained in a
motor vehicle or aircraft crash. A child who travels on the lap of
another occupant or unrestrained in a motor vehicle has a substantially
greater risk of injury and death, compared with a restrained
child.16-18 Hazards associated with the on-lap position
are also well documented in aircraft crash investigations. Three
children on the laps of adults were fatally injured and others
nonfatally injured in the 1987 crash in Denver, CO, the 1989 crash in
Sioux City, IA, and the 1994 crash in Charlotte, NC The FAA's Civil Aeromedical Institute (CAMI) has conducted
studies on CSSs for use with aircraft seats. Crash testing of CSSs using child dummies in 1993 revealed that rear-facing CSSs performed well and could be installed with contemporary aircraft seat belts. However, 6 of the 8 tests with forward-facing CSSs resulted in Head
Impact Criteria values of more than 1000, which is the threshold for
serious head impact in adults. Difficulty was encountered in securing
some of the forward-facing CSSs to the aircraft seats. Moving the
anchor points rearward resulted in improved performance of many CSSs;
however, most aircraft have seats with poor belt anchor
geometry.22
Certain restraints that are approved for use in motor vehicles are
prohibited for use in aircraft (14 CFR 121.311).7 When
tested, vest and harness type systems allowed excessive forward body
excursion, causing the test dummy to slide off of the front of the
seat, potentially impacting the seat in front and resulting in
injuries.22,23 Shield type booster seats are incompatible
with aircraft seats because of the seatback breakover feature common on
airplanes.
Testing has shown that aircraft seat belts alone do not adequately
protect a child younger than 3 years.22,23 The CAMI has
developed and fully tested a prototype aircraft seat insertion
platform, which can be inserted under the CSS and secured to the
aircraft seat with the seat belt. Seat belts attached to the platform
are used to secure the CSS. The platform improves ease of installation
and decreases the forward excursion of the CSS. A CSS designed for use
in aircraft that could be used forward or rear facing is a second
alternative. One such device is already approved and is being sold. A
third alternative is modifying a certain number of passenger seats on
each aircraft to accommodate and ensure adequate performance of CSSs. A
relatively simple and low-cost modification has been successfully
demonstrated at CAMI. The Society of Automotive Engineers (SAE) has
recently adopted a performance standard for CSSs installed on airplane
passenger seats.24 The objective of this standard is to
establish performance criteria for CSSs when installed in airplane
seats. The methods of meeting the SAE standard and the pass/fail
criteria are similar to those already imposed on CSSs by automotive
regulations (49 CFR 571.213). Inclusion of the SAE standard in
automotive regulations for CSSs should be considered.
A national symposium was held by the NTSB in 1999 to explore operation,
design, regulations, and experience with CSSs nationally and
internationally.25 At this meeting, FAA Administrator Jane
Garvey announced "... We [FAA] are committed to 2 things The NTSB has documented events in which children 2 years and older
have been transported on the lap of an adult. The NTSB has been
concerned about the inadequacy and lack of enforcement of passenger
protection regulations and has recommended that the FAA implement
measures for enforcing restraint regulation for children 2 years and
older.26
Consistent with national policies requiring restraint use in all
vehicles, the AAP recommends that regulations be promulgated to ensure
that all passengers, including those younger than 2 years, are afforded
optimal protection during all phases of commercial and general aircraft
flights. The AAP believes that children should be afforded the same
protection as other passengers and that restraint use in aircraft for
children younger than 2 years should be mandatory during takeoff,
landing, and conditions of turbulence and should be recommended as much
as feasible during flight as it is for all other passengers.
Pediatricians, federal agencies, and airlines are encouraged to
work together to accomplish the following:
INTRODUCTION
Top
Abstract
Introduction
Background
Recommendation
References
CURRENT POLICY FOR CHILDREN
BACKGROUND
Top
Abstract
Introduction
Background
Recommendation
References
which were all
caused by turbulence.19-21 The NTSB has reported 2 crashes in which CSSs were used and provided protection to
children.3
CERTIFICATION OF CSSS FOR USE ON AIRCRAFT
POTENTIAL NEW TECHNOLOGY
mandating the use of child restraint systems in aircraft and
assuring that children are accorded the same level of safety as are
adults." This statement clearly implies the FAA plans to move forward
with regulatory actions mandating the use of effective CSSs in
airplanes.
ENFORCEMENT OF EXISTING RESTRAINT REQUIREMENTS FOR CHILDREN
RECOMMENDATIONS
Top
Abstract
Introduction
Background
Recommendation
References
5. Establish international standards through the International Civil Aviation Organization requiring that passengers on civil aircraft be restrained during takeoff and landing and when directed by the captain of the aircraft.
6. On all types of passenger aircraft, pursue technologic solutions for improving restraint systems for children who are inadequately protected by existing child restraints or seat belt systems.
7. Educate all airline personnel who have contact with families regarding the importance of, and the requirements for, age-appropriate restraint use on aircraft. This includes travel agents, reservation/gate agents, and cabin crew.
8. The airlines should make available to families CSSs that are compatible and effective in aircraft.
9. Encourage airlines to offer a discounted fare (or a rebate) for restrained children.
Pediatricians should convey the following information to parents:
There is a need for accurate exposure data. Accurate passenger manifests should be generated to include all passengers on all flights. Standard reporting for all passenger injuries should be established and made available by age of passenger and restraint use. Epidemiologic studies and the evaluation of preventive measures may thus be conducted.
Committee on Injury and Poison Prevention, 2001-2002
Marilyn J. Bull, MD, Chairperson
Phyllis F. Agran, MD, MPH
H. Garry Gardner, MD
Danielle Laraque, MD
Susan H. Pollack, MD
Gary A. Smith, MD, DrPH
Milton Tenenbein, MD
Joseph Wright, MD, MPH
Liaisons
Ruth A. Brenner, MD, MPH
National Institute of Child Health and Human Development
Stephanie Bryn, MPH
Health Resources and Service Administration/Maternal and Child Health Bureau
Alexander Sinclair
National Highway Traffic Safety Administration
Richard A. Schieber, MD, MPH
Centers for Disease Control and Prevention
Lynn Warda, MD
Canadian Paediatric Society
Deborah Tinsworth
US Consumer Product Safety Commission
Consultants
Murray L. Katcher, MD, PhD
Van Gowdy
Howard R. Spivak, MD
Staff
Heather Newland
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FOOTNOTES |
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The recommendations in this statement do not indicate an exclusive course of treatment or serve as a standard of medical care. Variations, taking into account individual circumstances, may be appropriate.
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ABBREVIATIONS |
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AAP, American Academy of Pediatrics; CSSs, child safety seats; FAA, Federal Aviation Administration; NTSB, National Transportation Safety Board; CFR, Code of Federal Regulations; CAMI, Civil Aeromedical Institute; SAE, Society of Automotive Engineers.
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REFERENCES |
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Abstract
Introduction
Background
Recommendation
References
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Statement of reaffirmation:
This article has been cited by other articles:
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  S. M. Resnick, G. L. Hall, K. N. Simmer, S. M. Stick, and M. J. Sharp The Hypoxia Challenge Test Does Not Accurately Predict Hypoxia in Flight in Ex-Preterm Neonates Chest, May 1, 2008; 133(5): 1161 - 1166. [Abstract] [Full Text] [PDF]
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 E. J. Molloy Increasing Infant Safety in Air Travel: Deficiencies Are Not Limited to Child Restraint Systems Arch Pediatr Adolesc Med, November 1, 2004; 158(11): 1093 - 1093. [Full Text] [PDF]
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 T. B Newman The power of stories over statistics BMJ, December 20, 2003; 327(7429): 1424 - 1427. [Full Text] [PDF]
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T. B. Newman, B. D. Johnston, and D. C. Grossman Effects and Costs of Requiring Child-Restraint Systems for Young Children Traveling on Commercial Airplanes Arch Pediatr Adolesc Med, October 1, 2003; 157(10): 969 - 974. [Abstract] [Full Text] [PDF]
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