Standards overhaul is a low priority
Chassis subject to safety rules; passenger cabin excluded

By Lisa Zagaroli / Detroit News Washington Bureau

Sunday, January 26, 2003

The National Highway Traffic Safety Administration, the federal agency that regulates auto safety, doesn't have a crash standard for the entire ambulance and suggests it might take decades to create one.

The chassis and front seat of an ambulance have to meet federal safety regulations that govern everything from fuel tank integrity to brake performance. Ford Motor Co., which makes 85 percent of ambulance chassis, incorporates some passenger car features like air bags and softer components into the front seating compartment, even though it is not required to do so on vehicles in higher weight categories, said Alex I. Jowa, supervisor of the modified vehicle engineering quality programs section.


The agency specifically excludes the rear compartments of ambulances from federal regulations meant to minimize head injury in a crash.

Insufficient safety regulations for ambulance patient compartments contribute to unnecessary injuries and fatalities, according to a safety researcher.

"The rear cabin has no automotive safety regulations, it has minimal if any structural crashworthiness features that relate to impact, and no one has really studied the occupant restraint systems in any way," said Dr. Nadine Levick, the only safety researcher in the nation to conduct crash tests of ambulances.

"If you have a combination of restraints, head protection and padding, maybe you could cut it in half, maybe more," Levick, an emergency room physician at Harlem Hospital, said of the injuries and deaths that occur each year in ambulances.

Limited standards

The only criterion the rear compartments typically comply with is known in the industry as the "Star of Life" standards, which are purchase specifications spelled out by the government's General Services Administration. Though the guidelines really only apply to companies using federal money to buy ambulances, they have become the de facto standards for the 35 or so ambulance manufacturers in the United States that produce the rear compartments.

Updated in June 2002, the standards include few details about performance, nor were they designed to.

"Lighting systems, five pages; three pages on paint work; but when it comes to a vehicle that has a high fatality rate per miles traveled, we have 2 1/2 lines of text on occupant protection," Levick said.

The purchase standards deem an ambulance sound if it is driven only 150 miles without failure of any major component, vibration due to misalignment, or other evidence of structural weakness. Also, the body must stay intact and the doors must open when 150 percent of the vehicle's weight is loaded on the roof.

Even some ambulance manufacturers say those standards may not be stringent enough to ensure safety in crashes.

"In the past few years we have seen some serious accidents, which resulted in catastrophic structural failure" of some company's vehicles, said Mark Van Arnam, president of American Emergency Vehicles, an ambulance manufacturer. "In some cases, EMS personnel were actually ejected from the patient compartment and suffered serious injury or death."

Van Arnam

Van Arnam said the patient compartments, or "modular bodies," were presumably tested to the industry standard and still failed.

"It is obvious that a need exists for higher levels of testing and certification of modular body structural integrity to help the purchaser further verify what they are buying," he told customers in explaining why his company toughened its own testing procedures.

Standards revisited

NHTSA has no immediate plans to strengthen ambulance regulations, though it has agreed to consider the issue with the National Institute for Occupational Safety and Health. The agencies are conducting an in-depth analysis of four ambulance crashes to see if there are any trends that might lead them to make safety recommendations, said Jeff Michael, who was chief of NHTSA's emergency medical services division until November.

A dynamic crash test is unlikely, though, because it could take years, even decades, to come up with a "representative" crash scenario and a repeatable test, Michael said. It's complicated by the made-to-order nature of ambulances because many of them are different, making it more difficult to come up with a uniform standard.

"Our typical crash testing is done for two reasons, either to check for compliance with standards or to rate vehicles based on how they perform to change consumer behavior," said NHTSA Administrator Dr. Jeffrey Runge. "The latter is really not appropriate for ambulances. We need to get practical information into the hands of people who construct them. It's not typically the automobile manufacturers, it's the aftermarket. It's a multi-stage vehicle."

The agency tends to focus on problems that result in higher numbers of deaths each year. About 42,000 people die on the nation's highways each year, and about three dozen of them are in ambulance crashes.

Ambulances, as well as motorhomes and certain vans, are exempt from head impact rules because they have unsual equipment and design features that aren't covered by the regulation, NHTSA spokesman Tim Hurd said.

"Most importantly, occupants in the rear compartment areas of these vehicles are not likely to impact the head targets specified in (the regulation)," he said, adding that padding the areas wouldn't be practical because it would either interfere with the operation of the vehicle or have an excessively high cost.

Aside from the injuries and deaths that the crashes cause, monetary loss from property damage, increased insurance premiums and liability payments in some venues have eclipsed that of any other negligence-related EMS problem, according to the National Association of Emergency Medical Services Physicians and the National Association of State EMS Directors.

An 11-year analysis of fatal crashes published last year in Prehospital Emergency Care found that most serious and fatal injuries inside ambulances occurred in the vehicles' rear.

A paper published in December in the Annals of Emergency Medicine found that medics have a higher rate of death in crashes than police officers or firefighters.

"I wouldn't say it's not a priority," Michael said, about NHTSA's position on improving ambulance safety. "Certainly the agency is driven to invest its resources where the return to the public will be the highest. Return for investment in the ambulance area will be somewhat lower than other areas."