CHILD SAFETY SEAT INSPECTIONS STRATEGIC ANALYSIS OF COMMUNITY RISK REDUCTION BY: Bridget Bushue Anchorage Fire Department Anchorage, Alaska An applied research project submitted to the National Fire Academy As part of the Executive Fire Officer Program November 1999 ABSTRACT 2 The problem was that although Alaska law requires child safety seats and seat belts, no formal plan existed to confirm proper installation for those who were in compliance with the law. The purpose of this research was to evaluate the feasibility of adopting a child safety seat inspection program within the Anchorage Fire Department response area. The research employed both descriptive and evaluative research methodologies. The research questions were: 1. Is the Anchorage Fire Department the most effective organization that can provide the primary service? 2. What were the anticipated benefits and impacts upon the Anchorage community? 3. What organizational changes will be required by the Anchorage Department to facilitate adoption of a safety seat inspection program? The procedures involved analysis and comparison of motor vehicle accident statistics in Anchorage the nation. Current service agencies both public and private were evaluated. Surveys were conducted of fire department employees holding the rank of Engineer, Captain and Senior Captain. In addition 65 residents, either current parents or care providers were surveyed on vehicle restraint requirements. The results indicated that citizens are lacking in knowledge regarding proper installation of safety seats. There are great misconceptions regarding 3 size, weight, ages of children, and the corresponding safety seat. Both survey groups agreed that verification of safety seat installations within specific parameters would reap positive benefits; resulting in a decrease of serious and fatal injuries to children. The recommendations were to: a) provide certified training for prevention, suppression, and medical personnel on safety seat inspections, b) establish a multi-agency media and marketing campaign for safety seats and seat belt usage, c) consolidate existing area-wide training for comprehensive health and safety education; including education and information components for citizens, and, d) expand partnerships between public and private agencies within the child safety profession. TABLE OF CONTENTS 4 Abstract……………………………………………………2 Table of Contents………………………………………..4 Introduction……………………………………………….5 Background and Significance…………………………..6 Literature Review………………………………………...9 Procedures……………………………………………….13 Results……………………………………………………16 Discussion………………………………………………..19 Recommendations……………………………………….21 Appendix A………………………………………………..23 Appendix B………………………………………………..24 References………………………………………………..25 INTRODUCTION 5 The problem was that although Alaska law requires child safety seats and seat belts, no formal plan existed to confirm proper installation for those who were in compliance with the law. The purpose of this research was to evaluate the feasibility of adopting a child safety seat inspection program within the Anchorage Fire Department response area. The research employed both descriptive and evaluative research methodologies. The research questions were: 1. Is the Anchorage Fire Department the most effective organization that can provide the primary service? 2. What were the anticipated benefits and impacts upon the Anchorage community? 3. What organizational changes would be required by the Anchorage Fire Department to facilitate the establishment of a safety seat inspection program? The project approach was based upon two key principles. First, continue to support and enhance existing efforts to promote and encourage adults to use seat belts. Involve both public agencies and private organizations that currently provide community leadership within the vehicle restraint system and child safety arena. Second, once safety seats and seat belts are in use, ensure proper installation through the use of education, information, and inspection. Capitalize on existing resources by incorporating fire service, emergency medical and enforcement personnel as active participants in passenger protection and injury prevention. BACKGROUND AND SIGNIFICANCE 6 The Alaska State Legislature passed a law (AS 28.05.095) in June of 1984, requiring children aged six and under to be restrained while being transported (Child Seat Belt Act,1984). In February of 1989 the legislature amended the original provision of the Child Seat Belt Act. Children less than four years of age were to be placed in a restraint that complies with federal safety standards (Child Seat Belt Act,1984). Primary enforcement seat belt laws allow police officers to stop and ticket a driver for not wearing a seat belt, similar to other routine traffic violations. Sixteen states and the District of Columbia have enacted these laws according to the National Safety Council (NSC,1999a). Alaska and the remaining 32 states have secondary laws that allow law enforcement officers to ticket a driver only if the person has been stopped, or ticketed for another violation (NSC,1999a). Motor vehicle crashes are the leading cause of death for children of every age, (NHTSA,1998c). Despite numerous campaigns, programs, and public education efforts promoting the use of safety belts and car seats, vehicle crashes continue to kill and seriously injure children at an alarming rate. Six out of every ten children killed in crashes are unbelted (NSC,1999a). In 1998, the Anchorage Police Department issued a total of 1153 citations for safety seat and seat belt violations (Anchorage Police Department,1998). 7 Safety seats, when correctly installed and used, are extremely effective in saving lives. Research has found that child safety seats reduce fatal injury by 71% for infants (less than 1 year old) and by 54% for toddlers (1-4 years old) in passenger cars (NHTSA,1998b). The Alaska Safe Kids (ASK) coalition conducted between 800 to 900 car safety seat inspections between May of 1998 and February of 1999 (Alaska Safe Kids,1999). Anchorage has an 85% rate of incorrect installation (ASK,1999) compared to the national data of 80% (National Safe Kids,1999). Anchorage and the rest of the nation both had an 11% rate of grievous misuse (child less than one year turned facing forward rather than backward) during the same time period (ASK, 1999). In addition to incorrect installation, only 5% of booster seat age children ride in booster seats (Karp,1999, p.77). Well-intentioned parents and care providers have been shocked to find they were restraining their children incorrectly. Proper installation and use is a critical factor. Studies have found that as many as four out of five car seats are installed or used incorrectly (NHTSA,1995). Safety seats can be complicated. Errors are very common. Contributing factors to the difficulty of using seats properly include: a variety of age and size requirements; compatibility between car seat and the vehicle itself; improper seating position; and definite gaps in child occupant protection laws (NSK,1999a). In addition, improper installation can’t always be readily observed or recognized by the most well intentioned 8 driver or care provider, unless that individual has been educated on correct safety seat and seat belt installation (NSK,1999a). There are numerous vehicles and safety seat models. Each and every child safety seats requires a two-step process. The safety seat itself must be properly and firmly attached to the vehicle. The child must then be properly secured to the safety seat. There are no exceptions to these basic requirements (Breitenbach, Carnes, & Hammond,1995). According to Alaska Safe Kids, 60% of Anchorage drivers fail to tighten the safety belt that holds the seat to the vehicle. Another 34% fail to tighten the harness straps around the child (ASK,1999). Ejection from the vehicle is one of the most injurious events of motor vehicle crashes (NHTSA,1998b). These errors can be effectively corrected through a hands-on safety seat checkup. The Anchorage Fire Department responds to more than 2500 vehicle accidents each year (Anchorage Fire Department, 1998). The northern climate and hazardous road conditions, hours of daylight, and significant alcohol consumption, all contribute to high-risk driving behaviors. Fire stations are strategically located throughout the city. Compared to other public and private agencies, these stations would be ideal for safety seat inspection sites. The department enjoys an excellent relationship with the community. Paramedics and firefighters are intimately involved with safety and injury mitigation. As the department is “open” every day, weekend and evening checkups are easily accommodated. 9 The “Introduction To Community Risk Reduction” (National Fire Academy, 1997) offered through the Strategic Analysis of Community Risk Reduction course at the National Fire Academy (NFA) provided the necessary procedures and outlines to follow. I learned how to develop coalitions and promote educational and behavior changes. Verification of proper safety seat installation is a “primary prevention activity” discussed throughout the course. These were essential skills, which evolved into critical factors with this study. LITERATURE REVIEW There is a critical relationship between motor vehicle restrains systems and the extent of traffic fatalities and serious injuries according to NHTSA, the National Highway Traffic Safety Administration. Safety ranks quite high in vehicle purchase decision, and the public prefers a strong role by the government in setting safety standards (NHTSA,1996a). During a survey in 1995, NHTSA noted that 81% of respondents felt that vehicle safety standards for all fifty states, should be the same (NHTSA,1996a). All fifty states have child occupant protection laws, yet there is variation from state to state regarding age, size, and weight limitations. Many of the laws have serious gaps and exemptions in coverage which diminishes the protection children need (NHTSA,1996b). States with primary laws have seat belt use that is consistently 10 to 15 percentage points higher than secondary law states, as in Alaska (NSC,1999a). 10 According to the National Safety Council, adults who don’t buckle up are far less likely to buckle up kids (NSC,1999a). Studies have shown that when a driver is buckled, children riding with them are buckled 94% of the time. When drivers are unbuckled, child restraint use drops to 30% (NSC,1999a). Other compelling reasons support primary seat belt laws. Failure to buckle up contributes to more fatalities than any other single traffic safety-related behavior (NSC,1999d). Of the children under the age of five who died in motor vehicle crashes in 1997, more than half were completely unrestrained. Of those who were restrained, 39% were not in age and size appropriate safety seats, but rather were buckled in adult seat belts ( NHTSA,1996c). We all pay higher health care and insurance costs because of unbelted drivers and passengers (Saperstein,Saperstein,1994). Society picks up 85% of these costs, not those individuals involved in the crash (NSC,1999d). “13% of Americans who regularly drive children age twelve and under actually admit that they don’t always make sure children are buckled up” (NSC,1999d,p.1). Government data shows that one out of four children ride completely unbuckled, putting more than fifteen million kids at risk (NSC,1999d). The Alaska Trauma Registry reports that 178 children under the age of 15 required hospitalization between 1991 and 1998 (Alaska Trauma Registry, 1999). The evidence is clear. To protect children we must reach the adults. Studies have shown that the most effective way to get adults to wear seat belts is through the passage of primary enforcement seat belt laws (NSC,1999d). 11 Primary laws will enable police officers greater authority for more effective enforcement (NSC,1999d). Technological advances have improved safety seats and seat belts. Air bags have greatly impacted the proper placement of children in the vehicle (NHTSA,1999). Children must be properly restrained in the back seat in any vehicle that has an air bag (NSC,1999b). With or without air bags, the rear seat is the safest place for children to ride (NSC,1999b). Several European countries have requirements that all children under the age of twelve must ride in the back seat (National Swedish Road Safety Office,1999). This has been a law in Germany for more than twenty years. This requirement is currently a strong recommendation throughout the United States (NHTSA,1996b). Many parents believe that if booster seats aren’t mandatory they are unnecessary. Booster seats raise the child so that the vehicle’s lap and shoulder belt fit properly. Generally children under 80 pounds and 58 inches tall should ride in a booster seat (Breitenbach, Carnes, & Hamond,1995). The early graduation of children from safety seats into adult lap and shoulder belts is one of the leading causes of child-occupant injuries and deaths according to the Automotive Coalition for Traffic Safety (Karp,1999). Booster seats are effective only when used with the appropriate lap and shoulder belts. Vehicles built before 1989 were not required to have shoulder straps in rear seats (Karp,1999). 12 Physical hands-on inspections are one of the most effective methods to ensure proper installation and correct use of child safety seats and seat belts (NSK,1999b). Children are not small adults, and they need special protection. Their skulls are more fragile, their heads proportionately larger, their rib cage is thinner, and they’re shorter (NSC,1999c). There are a wide variety of motor vehicles, numerous types of belts, and ever changing safety seats themselves. These three components are critical to protect passengers (NHTSA,1997). The United States is the first country to adopt a requirement for universal anchor systems for child restraints (NHTSA,1999). The universal anchor rule will provide devices independent of safety belts to attach child restraints to the vehicle. It allows restraints to be anchored more securely than is possible with current seat belts (NHTSA,1999). The literature supports the fact that improper installation is a critical factor affecting child occupant protection. It reinforces the fact that improper installation can’t always be readily observed or recognized. But the literature emphasizes that improper installation can be corrected. Statistics readily illustrate that adults continue to require stronger regulations to ensure that children are protected. Evidence indicates that even the most diligent parent or guardian needs additional safeguards to ensure safety seats and seat belts are installed correctly. PROCEDURES 13 Population – Fire Department Employees Two sample groups were used for this study. The first were Anchorage Fire Department employees holding the rank of Engineer and Captain. A total of 77 personnel occupy these positions. 54 surveys were completed from the employees group. The second group consisted of Anchorage residents, who confirmed they were parents or care providers for children under the age of 16. A total of 52 citizen surveys were completed. Both surveys were tabulated and the data combined (See Appendix A and Appendix B). Instrumentation The goal for the employee surveys was to answer research questions one and three. Question one asked respondents whether they supported child safety seat inspections. Question two asked whether respondents had ever participated in a child seat inspection activity. Question three asked whether fire stations would be the most acceptable community location to hold safety seat inspections. Question 4 asked whether the employees had children, and what their ages were. Question 5 asked employees whether fire department employees should perform safety seat inspections, after obtaining the necessary training and certification. Question 6 asked employees to identify potential negative impacts or problems that could surface with current routine and training demands. Question 7 asked employees to select ways to evaluate the success or impact of the proposed program. 14 Assumptions and Limitations Employees surveyed are members of the Anchorage Fire Department, and include the rank of Engineer and Captain. There are 77 total employees in these ranks. They must have a minimum of 6 years service on the department. The surveys occurred over a six week period, with an exceptionally busy EMS activity period. Response was voluntary, no names or signatures were requested. Surveys were routed to the Captain in charge of their respective apparatus, and distributed to qualifying personnel. All 54 surveys were tabulated. No analysis occurred to determine the margin of error in the survey results. Population – Random Parents Surveys for the citizen group occurred over a two month period. Subjects were queried at the main city library on weekends. The Loussac Library has weekend reading programs and community events specifically targeted for young children. The Loussac is centrally located in Anchorage, and is the largest public library in the state of Alaska. It has quick and easy access for both vehicle and pedestrian traffic and ample parking. Subjects were approached as they entered the main exterior access stairway. Each entrant was asked whether they were a parent or care provider for children under the age of 16. Many had children in hand. If yes, they were requested to answer the survey. Each survey took approximately five minutes to complete. 80% of the respondents were female. 15 Instrumentation The goal of the citizen surveys was to answer questions one and two. Question one asked the parent if they always used a seat belt. Question two asked parents if they always buckled up children while they were driving. These questions were significant because research has indicated that if the parent doesn’t buckle up, the children won’t be buckled up either. Question three asked if the parent had installed their child’s safety seat. Question four was also critical. Did the parent know how much their child weighed? Question five asked whether their vehicle had air bags. Questions six and seven asked where the safety seat was placed, and whether children under twelve, ride in the front or back seat. Question eight asked how the program would impact or benefit the community. Question nine asked parents if they were aware of any groups or local organizations that currently perform safety seat inspections. Question ten asked parents if they would participate in a courtesy safety seat inspection at their nearest fire station. Assumptions and Limitations This survey was conducted at a public assembly occupancy. It is limited to those who attended the Loussac Library during the weekends of July and August 1999. Participation in the survey was voluntary. A total of 62 surveys were tabulated. No analysis was made to determine the margin of error. The surveys for the most part required a yes or no response. As the Loussac Library is centrally located, participants were not limited to any one geographical area. RESULTS 16 Answers to Research Questions Research Question 1: Is the Anchorage Fire Department the most effective organization that can provide the primary service? Many other departments have implemented safety seat inspection programs. The transformation from response to prevention can be tedious. Children and safety elicit a deeper response than other programs. Of the employee surveys, 98% of the respondents had children, yet 97% had not participated in a child safety seat inspection of their own safety seats. Support for the inspection program was strong, provided time allowance and training goals were adjusted to accommodate additional duties. Liability was a major caveat. This issue is the “make or break” roadblock. This question generated a whole plethora of related questions. Use of the stations for the inspections was supported, as long as the inspections were on controlled dates and times. Random inspections would be difficult due to normal emergency response activity. Training was another area of concern. Certification and education incentives were suggested, but training demands currently exceed availability. The parent group supported the Fire Department’s role as the lead agency. Paramedics and firefighters are the most qualified to fill the need. The available work hours and the facilities themselves were ideally suited for the task. Parents felt that the employees would be confident in performing the inspections. Only 6 of the parental respondents were aware of Safe Kids, but knew of no other agency or organization that currently perform safety seat inspections. 17 Two respondents had participated in inspection programs in Oregon. The courtesy inspection participation was positive. All except two individuals stated they would participate. A free service for child safety was well received. Some parents were concerned over punitive or legal action if their seats failed to pass the inspection. Would they get a ticket right then and there? Research Question 2: What were the anticipated benefits and impacts upon the Anchorage community? Both survey groups felt that decreased serious injuries and fatalities for children would be a direct result of installation inspections. Education and information would be secondary results, with a significant increase in understanding of restraint systems. Many parents had little knowledge of proper safety seat location and installation. 30% stated they knew what their children weighed, only because they had recently visited their pediatrician. 60% still transported their children in the front seat (all pick-up trucks don’t always have a back seat). Of the 60%, 3 parents stated that they did not have air bags. All respondents had installed or had another family member install their safety seats. 90% stated they always buckled up children, but 26% did not always buckle up themselves. This was interesting, as research literature indicated that if the adults buckles up, then the child is buckled. Employees felt that response statistics would most likely remain the same, but severity of injuries and numbers of fatalities should decrease. In addition, the number of citations for noncompliance should decrease. As more education 18 and information was distributed, fewer violations would probably occur. The trend for injury prevention has been emerging. The positive benefits of fewer injuries and less severe injuries can be measured. Information about other safety organizations and other child advocate groups would serve to increase the awareness of vehicle restraint systems community wide. Additional impacts on the community may be increased demands for changes in the current laws. Exemptions should be eliminated for overcrowded vehicles. In nearly half the states, children can ride unsecured, if all safety belts are in use (NHTSA,1996b). Drivers may be held responsible for all children under the age of 16. Current safety belt law states that the parent or guardian has responsibility for children under 16, and they may not be the driver, or even in the car with the child. Research Question 3: What organizational changes would be required by the Anchorage Fire Department to facilitate the adoption of a safety seat inspection program? More than 86% of the employees stated that with current tasks, hours, and staffing levels it would be difficult to devote large amounts of time to these inspections. However, if the program had specific controls and time limits, they would support it. Training would have to be a department priority. As this program is more “outside the norm” than usual department activities, there will be less organizational changes and more adaptive changes to fit the demands of the program. DISCUSSION 19 The purpose of this research was to evaluate the feasibility of adopting a safety seat inspection program. The evaluation includes recommendations for adjustment to current department demands and entering into an interactive role with the community. The study results are compatible to the findings of others in the literature review. All agree that we must convince or demand that adults and children must use restraints. These safety seats must be installed correctly. To ensure this, visual and hands-on inspections may be performed. Education and information needs to occur simultaneously. Once the seat belts are being used and are correctly installed, the laws must be enforced. NHTSA recommends strengthening current laws and closing the gaps on exemptions (NHTSA,1996b). Raise the age limit on child restraint laws to cover up to age 16. Convert all secondary to primary enforcement laws. Make it illegal to carry children in the cargo areas of pickup trucks. Eliminate exemptions for overcrowded vehicles. Last but not least NHTSA recommends eliminating the exemption for “attending” to the child. This encourages parents to carry children on their laps while feeding or other activities (NHTSA,1996b). The surveys indicated that drivers need to be educated. Research indicated that more than 80% of safety seats are improperly installed (NSK,1999a). Without proper installation, children are at risk, and parents face a false sense of security. 20 The Anchorage Fire Department can take the lead and initiate the process to combat the problem. Safety seat inspections demand simple but necessary actions. Fire and emergency medical responses are gradually making the transformation from response to mitigation. Additional training and education is necessary. The evidence is overwhelming. Incorrect installations of child safety seats include; safety belt not holding the child safety seat tight enough; harness straps not snug enough; retainer clip placed at chest level (it should be at armpit level); use of a safety seat that’s been recalled; harness straps incorrectly routed; child less than one-year old facing forward; and failure to use a locking clip where the seat belt doesn’t automatically lock (NSK,1999b). Of the more than 1000 citations issued by the Anchorage Police Department, 501 citizens were cited for failing to wear a seat belt. 366 were cited for failing to have children under the age of 16 in a seat belt. Another 265 drivers were cited for failing to provide a child safety seat. (Anchorage Police Department,1998). Literature supports the demand for stronger enforcement. Even after all of the statistics, the massive seat belt campaigns, the fatalities, and the laws themselves, it’s unbelievable that people today still don’t or won’t wear a seat belt or provide a safety seat for children. Every day an average of seven children ages 14 and under die and another 908 are injured in motor vehicle related crashes (NHTSA,1998c). RECOMMENDATIONS 21 There is a need and a demand for safety seat inspections. Child fatality and injury statistics are quite clear and confirm data derived from the literature review. As far back as 1986, studies have indicated that seat belts and safety seat usage though on the increase, still remain an option for some (Hanna,Kruse,1992). It is recommended to adopt a safety seat inspection program, coordinate efforts with existing health and safety organizations, and to reorganize specific areas within the Anchorage Fire Department. Methods of Implementation In order to adopt and implement a program, it will be necessary to provide certified training for medical, fire, and prevention personnel. Partnerships with established child and safety advocates will be necessary. No one agency can effectively work alone. A multi-media and marketing campaign is necessary to increase public awareness. Health and safety education training for the citizens is a critical component. All care providers and parents must know: a) how to install a safety seat, or b) where to go to make sure the seat is installed. A pilot program at one single station can be utilized as the training ground. Identifying destabilizing forces within the organization is essential. Establishing the pilot program will help troubleshoot for upcoming problems. Many employees have been through numerous programs and therefore are cynical and skeptical. Many will have the “wait and see” attitude. Failure to provide effective communications can sabotage the entire program. Employee support is critical. 22 There are numerous agencies and organizations that all contribute to safety seat and seat belt awareness and concern. Integrating first responders with these organizations will help create a greater understanding of the problem. The more people understand the goal, the easier the battle. Inspections will bring the community to the stations. An organized approach can provide a community service with the greatest of return. The statistics are clear. Safety seats and seat belts save lives. Proper installation is critical. Education and information will provide parents the necessary knowledge to ensure their child’s safety, and in turn save their lives. Borrowing from existing inspection programs already operating can assist the Anchorage Fire Department when selecting the criteria for its program. Publicity and education can raise the awareness of proper child passenger protection. Many parents and others who transport children do not understand the potential deadly results from errors in seat installation. This inspection program can eliminate those errors. APPENDIX A 23 Child Safety Seat Inspection Program Survey 1. Would you support a child safety seat inspection program? YES_____ NO_____ Comments:________________________ 2. Have you ever participated in a child safety seat inspection? YES_____ NO_____ Comments:_______________________ 3. Are fire stations the most effective locations for community interaction? YES_____ NO_____ Comments:________________________ 4. Do you have children? YES_____ NO_____ 5. With proper training/certification should fire department personnel perform inspections? YES_____ NO_____ Comments:________________________ 6. With current training and routine demands list any negative impacts which might affect you at your present duty station: Not enough time_____ Other______________________ Workload demands_____ Liability concerns_____ 7. How would you rate or evaluate the success or improvement of the program? (Check All That Apply) Reduction of improper installations____ Reduction of motor vehicle child serious injuries____ Reduction of motor vehicle child fatalities____ Increased public awareness for correct child safety seats____ Increased compliance of safety seat and compliance____ Reduction of citations for safety seat noncompliance____ Other________________________________________________ 8. Any additional suggestions,comments, input, ideas, complaints… _____________________________________________________ _____________________________________________________ APPENDIX B 24 Anchorage Fire Department Child Safety Seat Information Survey 1. Do you always use a seat belt? YES___NO___ 2. Do you always buckle up children while you’re driving? YES___NO___ 3. Did you install your child’s safety seat? YES___NO___ 4. Do you know today – how much your child weighs? YES___NO___ 5. Does your vehicle have air bags? YES___NO___ 6. Where do you place your safety seat? Front Seat____Back Seat____ 7. Where do your children under age 12 ride? Front Seat____Back Seat____ 8. How would you rate the success or improvement of the program? Number of injuries___ Reduction of fatalities___ Number of citations___ Reduction of serious injuries___ 9. Are you aware of any groups or organizations that currently perform child safety seat inspections? YES___NO___ 10. Would you participate in a courtesy safety seat inspection program? YES___NO___ Comments:_____________________________ Thank you for your participation in this safety information survey. If you have further questions please call 267-4972. The Anchorage Fire Department REFERENCES 25 Alaska Safe Kids(AKS). (1998) Incorrect installations of child safety seats. Anchorage, AK. Alaska Trauma Registry. (1998). Alaska children and youth motor vehicle occupant injuries on the highway. Juneau, AK: Dept. of Health and Human Services, State of Alaska. Anchorage Fire Department. (1998) . End of year report. Anchorage, AK: Municipality of Anchorage. Anchorage Police Department (1998). Annual statistical report. Anchorage, AK: Municipality of Anchorage. Breitenbach,J., Carnes,J., Hammond,J., (1995). Baby seats, safety belts and you. Richmond, VA: Virginia Commonwealth University. Child seat belt act, 5 Alaska Statute. 28.805.095 (1984). Hanna,V., Kruse,J., (1992) An assessment of safety belt use in Alaska. Anchorage: University of Alaska, Anchorage, Institute of Social and Economic Research. Karp,H., (1999, November). Kids at risk, when seat belts are not enough. Reader’s Digest, p. 74-79. National Fire Academy. (1997). Strategic analysis of community risk reduction: student manual. Emmitsburg, MD: U.S. Fire Administration. National Safety Council (NSC). (1999a). Primary seat belt laws save kids. www.nsc.org/partners/primary. 26 National Safety Council. (1999). Air bag safety, buckle everyone. www.nsc.org/partners/safetips. National Safety Council. (1999). Why child safety seats. www.nsc.org/safety. National Safety Council. (1999). Air bag and seat belt safety. www.nsc.org/safety. National Highway Traffic Safety Administration (NHTSA). (1995, June) Estimating lives saved by restraint use. Washington, D.C: Government Printing Office. NHTSA. (1996a, August). Government role in highway safety. Technology Transfer Series, No. 132. Washington, D.C: Government Printing Office. NHTSA. (1996b), September. Strengthening child passenger safety laws. State legislative fact sheet. Washington, D.C: Government Printing Office. NHTSA. (1996c). Passenger occupants killed by state and by restraint use. Traffic Safety Facts. Washington, D.C: Government Printing Office. NHTSA. (1997, March). Video Protecting your newborn. Produced by Ford Motor Company. NHTSA. (1998a). Revised estimates of child restraint effectiveness. Research notes. National Center for Statistics and Analysis. Washington, D.C: Government Printing Office. 27 NHTSA. (1998b). Occupant protection. DOT HS 808 954. ww.nhtsa.dot.gov. National Highway Traffic Safety Administration (NHTSA). (1998c). Children. DOT HS 808. www.nhtsa.dot.gov. NHTSA. (1999) Universal anchor standard for child restraints. Safety Technical Report . Spring. www.nhtsa.dot.gov/people/injury. National Safe Kids (NSK). (1999A) Child passengers at risk in America, a national study of car seat misuse. www.safekids.org. NSK. (1999b). Safe kids buckle up, program profile. www.safekids.org. Saperstein,R., Saperstein,D., (1994). Surviving an auto accident. Ventura, CA: Pathfinder Publishing of California. The National Society for Road Safety. (1999). The Swedish national road safety programme, a new approach for road safety. www.ntf.se.
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