Aviation, Space, and Environmental Medicine x Vol. 80, No. 12 x December 2009
B AKER SP, B RADY JE, S HANAHAN DF, L I G. Aviation-related injury
morbidity and mortality: data from U.S. health information systems.
Aviat Space Environ Med 2009; 80:1001–5.
Introduction: Information about injuries sustained by survivors of air-
plane crashes is scant, although some information is available on fatal
aviation-related injuries. Objectives of this study were to explore the
patterns of aviation-related injuries admitted to U.S. hospitals and relate
them to aviation deaths in the same period. Methods: The Healthcare
Cost and Utilization Project (HCUP) Nationwide Inpatient Sample (NIS)
contains information for approximately 20% of all hospital admissions
in the United States each year. We identifi ed patients in the HCUP NIS
who were hospitalized during 2000 – 2005 for aviation-related injuries
based on the International Classifi cation of Diseases, 9 th Revision, codes
E840 – E844. Injury patterns were also examined in relation to informa-
tion from multiple-cause-of-death public-use data fi les 2000 – 2005. Re-
sults: Nationally, an estimated 6080 patients in 6 yr, or 1013 admissions
annually (95% confi dence interval 894 – 1133), were hospitalized for
aviation-related injuries, based on 1246 patients in the sample. The aver-
age hospital stay was 6.3 d and 2% died in hospital. Occupants of non-
commercial aircraft accounted for 32% of patients, parachutists for 29%;
occupants of commercial aircraft and of unpowered aircraft each consti-
tuted 11%. Lower-limb fracture was the most common injury in each
category, constituting 27% of the total, followed by head injury (11%),
open wound (10%), upper extremity fracture, and internal injury (9%).
Among fatalities, head injury (38%) was most prominent. An average of
753 deaths occurred annually; for each death there were 1.3 hospital-
izations. Conclusions: Aviation-related injuries result in approximately
1000 hospitalizations each year in the United States, with an in-hospital
mortality rate of 2%. The most common injury sustained by aviation
crash survivors is lower-limb fracture.
Keywords: accident , aviation , fracture , injury , lower limb , mortality ,
parachuting , survivors .
are important for crash reconstruction, evaluation, and
improvement of aircraft design and safety equipment,
and resolution of medicolegal issues. Previous research,
based primarily on autopsy or death certifi cate data, has
revealed the predominant role of head injury caused by
blunt trauma in aviation-related fatalities in both civil
and military fl ights ( 8,12,15 ). Information about serious
nonfatal injuries, however, has been lacking for civil
aviation crashes because the National Transportation
Safety Board (NTSB) and Federal Aviation Administra-
tion (FAA) do not systematically record injury data for
crash survivors. Consequently, to fi nd data on injuries to
survivors of aircraft crashes or other aviation-related
events, other data sources must be used. The present
study was undertaken to determine the number and
types of injuries present in hospitalized survivors of
NOWLEDGE OF INJURIES and the mechanisms of
injuries sustained by victims of aviation mishaps
From the Center for Injury Research and Policy, Johns Hopkins
Bloomberg School of Public Health, Baltimore, MD; and the Depart-
ment of Anesthesiology, Columbia University College of Physicians
and Surgeons and the Department of Epidemiology, Columbia Uni-
versity Mailman School of Public Health, New York, NY.
This manuscript was received for review in May 2009 . It was ac-
cepted for publication in August 2009 .
Address reprint requests to: Professor Guohua Li, M.D., Dr.PH., De-
partment of Anesthesiology, Columbia University College of Physi-
cians and Surgeons, 622 West 168th Street, PH5-505, New York, NY
10032; GL2240@columbia.edu .
Reprint & Copyright © by the Aerospace Medical Association,
Aviation-Related Injury Morbidity and Mortality:
Data from U.S. Health Information Systems
Susan P. Baker , Joanne E. Brady , Dennis F. Shanahan ,
and Guohua Li
aviation crashes and non-crash events such as parachut-
ing mishaps. Information on all fatally injured persons
was also obtained in order to estimate the total injury
burden associated with aviation.
The Healthcare Cost and Utilization Project (HCUP)
Nationwide Inpatient Sample (NIS) is a data system
sponsored by the Agency for Healthcare Research and
Quality that contains information for approximately 20%
of all hospital admissions in the United States ( 1 ). Using
the International Classifi cation of Diseases, 9 th edition,
codes for air transport accidents (E840 – E844), we identi-
fi ed patients in the NIS who were hospitalized through
emergency or urgent admissions for aviation-related in-
juries during 2000 – 2005. Users of the hospitalization data
are not permitted to publish numbers based upon fewer
than 11 patients. Mortality data came from the National
Center for Health Statistics’ multiple-cause-of-death
public-use data fi les for 2000 – 2005 (14). Aviation-related
deaths were identifi ed using International Classifi cation
of Diseases, 10 th edition, codes for air transport accidents
(V95.0-V95.3, V95.8, V95.9, V96, V97).
The estimated frequency distribution of aviation-
related injuries in hospitalized patients was tabulated
by victim type, discharge status, and length of stay. Fre-
quencies were estimated based on weighted analysis of
the HCUP NIS data. HCUP NIS discharge weights are
equal to the number of universal discharges it represents
in a stratum during that year ( 1 ). Injury- and victim-type-
specifi c hospital case-fatality rates were estimated as the
percentage of hospitalizations for aviation-related inju-
ries that died in the hospital. Statistical analysis was
1002 Aviation, Space, and Environmental Medicine x Vol. 80, No. 12 x December 2009
AVIATION INJURIES & DEATHS — BAKER ET AL.
performed using SAS version 9.2 (SAS Institute, Inc.,
Cary, NC). The study was based on publicly available
data and was exempted from review.
During the 6-yr study period, an estimated 6080 pa-
tients were admitted to U.S. short-term hospitals with
aviation-related injuries, based upon weighted analy-
sis of the 1246 admissions captured by the HCUP NIS.
The annual average number of patients was 1013 [95%
confi dence interval (CI) 894 – 1133]. The largest catego-
ries of patients were occupants of civilian, noncom-
mercial, powered aircraft (primarily general aviation)
(32%) and parachutists (29%). Occupants of commer-
cial aircraft and unpowered aircraft each constituted
11% of the total. There were 17% of the patients coded
as ‘ other ’ , which included ground workers as well as
passengers or crew injured outside the airplane.
A total of 9056 injuries (weighted number), averaging
1.5 diagnoses per patient, were listed on the hospital
discharge records. It was possible to code as many as 19
diagnoses for any patient. Lower limb fractures were the
most common injury and constituted 27% of all hospi-
talized injuries ( Table I ). Lower limb fractures were es-
pecially prevalent in parachutists, constituting 46% of
their injuries. They were also the most common injury in
each victim category: 28% of injuries to occupants of
commercial aircraft, 22% of injuries to occupants of un-
powered aircraft, and 17% of injuries to occupants of
noncommercial aircraft. Head injuries were the second
most common injury, constituting 11% of all injuries and
13% of injuries to occupants of noncommercial aircraft.
Open wounds constituted 10% of all injuries, while
TABLE I. AVIATION-RELATED INJURIES TREATED IN HOSPITALS, WEIGHTED ESTIMATES, BY VICTIM TYPE AND INJURY DIAGNOSIS,
HEALTHCARE COST AND UTILIZATION PROJECT NATIONWIDE INPATIENT SAMPLE, UNITED STATES, 2000 – 2005.
( N 5 643)%
( N 5 1970)%
( N 5 665)%
( N 5 1756)%
Other Person **
( N 5 1045)%
( N 5 6080)%
Injury to joint/
Other injury ‡
* Represent fewer than 11 patients, unweighted; the numbers are included in the totals.
† Includes general aviation, military, and other powered aircraft.
§ Up to 19 diagnoses per patient were counted.
‡ Includes International Classifi cation of Disease, Clinical Modifi cation, 9 th Edition (ICD-9), Nature of Injury Codes 850-900 that are not captured in
any other category.
** Other person is defi ned by the 4 th digit of the ICD-9 code.
upper-extremity fractures and internal injuries each
constituted 9% of all injuries.
Of the estimated 6080 hospital patients, 1114 (18%)
were transferred to facilities other than short-term hos-
pitals. The mean length of stay for all 6080 patients was
6.3 (95% CI 5.8 – 6.8) d. Of the injured, 75% were male. In
terms of age, 71% of patients were ages 20 – 59. The 40 –
49-yr age group was largest, with 22% of all patients.
An estimated 120 patients (weighted number) died in
the hospital, resulting in an inpatient case-fatality rate
of 2%. Based upon the primary injury diagnosis, the
highest case-fatality rates were for injuries to blood
vessels, burns, and head injuries (39%, 13%, and 8%,
Multiple-cause-of-death data for 2000 – 2005 revealed
that 4517 aviation-related deaths occurred in the United
States, an average of 753 per year. The ratio of hospital-
ized cases to total deaths was 1.3 ( Table II ). Analysis of
the multiple-cause-of-death data by category of victim
showed that 87% of persons who died were occupants
of powered aircraft that were not categorized as com-
mercial. Of fatally injured victims, 7% were occupants
of commercial aircraft and 3% were parachutists. The
patients with the highest ratio of hospital cases to deaths
(i.e., the lowest risk of death) were parachutists and
‘ others ’ . The patients with the highest risk of death were
occupants of noncommercial aviation; these victims,
with only half as many hospital admissions as deaths,
were primarily those injured in general aviation
Comparison of the results of multiple-cause-of-death
data analyses with mortality data from the NTSB for the
Aviation, Space, and Environmental Medicine x Vol. 80, No. 12 x December 2009
AVIATION INJURIES & DEATHS — BAKER ET AL.
same period ( 9 ) indicated close agreement in the total
number of aviation deaths during 2000 – 2005. The NTSB
reported 4555 deaths, less than 1% more than the num-
ber of deaths in the multiple-cause-of-death fi les. (A
direct comparison, involving matching of individual
multiple-cause-of-death data fi les.)
The present study is the fi rst published analysis of
aviation-related hospitalized injuries and deaths in the
United States. The enumeration of all such deaths dur-
ing the 6-yr 2000 – 2005 period plus a reliable estimate of
hospitalized patients in the same years allows us to cal-
culate a ratio of 1.3 hospital admissions for each death
(the 2% overlap involving the in-hospital deaths has a
negligible effect on this ratio). The annual number of
deaths published by the NTSB agrees closely with our
analyses of the multiple-cause-of-death data and, there-
fore, can be used in conjunction with this ratio; this pos-
sibility helps us to understand the magnitude of the
problem of aviation deaths and injuries.
In New Zealand, Chalmers et al. ( 4 ) reported on 120
hospitalizations of aircraft occupants in a 6-yr period
(1988 – 1993) and 104 deaths in 5 of those years. Adjusted
to 5 yr, the ratio of 100 to 104 (0.96 to 1) is substantially
lower than the U.S. ratio of 1.3 to 1 determined in our
analysis. The lower ratio in New Zealand may result
from the exclusion of parachutists, who on average are
less seriously injured, in the Chalmers et al. study. Other
factors that could have contributed to the lower injury-
death ratio in New Zealand might be more stringent
admission criteria and a larger proportion of general
aviation fl ights among all aviation crashes.
Our results describing the injuries of hospital patients
provide valuable information, not elsewhere available,
on the kinds of injuries incurred in aviation-related
events. The NTSB collects injury data on occupants in
some fatal airline crashes and publishes the annual num-
ber of injuries in airline (Part 121) crashes ( 10 ). Other-
wise, injury data are not published, nor are injury data
available for other categories of aviation. Knowledge of
the nature of injuries sustained, especially by aircraft oc-
cupants, is important for several reasons. First, data on
injuries can inform crash reconstruction and help us to
recognize needed changes in aircraft design. Most oc-
cupant injuries occur in general aviation crashes and
some injuries could be prevented through changes in
the designs of general aviation aircraft ( 7,15 ). The prom-
inence of lower limb fractures in hospitalized patients
in this study and in the fatality study reported by
Wiegmann and Taneja ( 15 ) underscores the potential
value of modifi cations to the various structures likely to
be contacted by feet and legs when a crash occurs. In
New Zealand, Chalmers et al. ( 4 ) also found that the
most common injury in crashes of fi xed-wing aircraft
was to the lower extremities, while spinal injuries were
more common in helicopter crashes.
Occupant injuries to the head and internal organs of
the chest and abdomen point to the need to consider
changes in aircraft controls. Similar to the placement of
an automobile steering wheel, the position of the wheel
or stick immediately in front of the pilot’s torso makes it
a likely contributor to injury, even among restrained oc-
cupants ( 7,12 ). Military studies have shown that injury
from aircraft controls accounted for approximately 5%
of injury sources in survivable crashes for which sources
of injury were identifi ed ( 12 ); therefore, side-mounted
controls have been recommended for both safety and
comfort. This confi guration is found in all Airbus air-
craft and some military aircraft. Since forces are gener-
ally frontal, it make sense to eliminate, wherever feasible,
hazards that are placed in front of pilots. Moreover,
many general aviation aircraft still in use do not have
upper torso restraints or have a detachable shoulder
belt. As in autos, upper torso restraint should not be
Our results are also pertinent to injured parachutists,
whose lower-extremity fractures constituted almost half
of all their injuries, suggesting the potential value of leg
braces or other protection devices for the lower extremi-
ties as well as lower-velocity parachute canopies and,
perhaps, modifi cations in landing fall procedures. Other
studies of sports parachuting and military parachuting
have produced similar fi ndings of a high incidence of
lower extremity injuries, particularly ankle injuries
( 2,5,6 ). The value of leg braces has been clearly demon-
strated in studies of U.S. Army Airborne Rangers, where
the use of an external ankle brace reduced the incidence
of ankle injuries by 67% ( 13 ). Also, a controlled study of
ankle brace use by students in airborne training showed
that students who did not use the brace were almost two
times as likely to suffer an ankle injury during a landing
as their counterparts using the ankle brace ( 6 ).
Secondly, our results can provide hospitals with use-
ful planning information on the spectrum of likely
TABLE II. AVIATION-RELATED INJURY HOSPITALIZATIONS AND DEATHS AND RATIO OF HOSPITALIZATIONS
TO DEATHS BY VICTIM TYPE, UNITED STATES, 2000 – 2005.
Type of Victim
Occupant of commercial aircraft
Occupant of noncommercial aircraft
Occupant of unpowered aircraft
1004 Aviation, Space, and Environmental Medicine x Vol. 80, No. 12 x December 2009
AVIATION INJURIES & DEATHS — BAKER ET AL.
injuries when they are expected to receive victims of an
aircraft crash. Extremity fractures, for example, are likely
to be present in one-third of aviation-related injury pa-
tients, and head and internal injuries are each seen in
about one-tenth of patients. Burns, while a major con-
tributor to aviation deaths, were seen in only 2.5% of
hospitalized patients. Nevertheless, hospitalized burn
patients had a high case-fatality rate (13%), accounting
for 17% of deaths among aviation victims. The case-
fatality rate for hospital cases indicates the degree to
which each type of injury is likely to be life threatening
to patients admitted following aviation mishaps. The
highest case-fatality rate, 39%, was in patients with in-
jury to blood vessels, followed by burn patients (13%),
and patients with head injury (8%).
Finally, hospitalization data may help to reveal
changes over time in the patterns of injuries in aviation
mishaps. This can help to document the effectiveness, or
lack thereof, of changes made to aircraft design, per-
sonal protective equipment, or regulations and proce-
dures. For example, changes in the numbers of thermal
injuries and their proportions among aviation injuries in
recent decades have been diffi cult to assess due to ques-
tions as to whether burns occurred before or after death.
Wiegmann and Taneja ( 15 ), studying autopsy data for
general aviation pilots, reported that in 1996 – 1999, ante-
mortem burns were present in 9% and postmortem
burns in 24%. Li et al. ( 8 ), studying U.S. death certifi -
cates for all aviation-related fatalities in 1980 and 1990,
found that burns were 4% and 3%, respectively, of the
injuries recorded for aviation deaths in those years. They
also noted a decrease in the annual number of fatalities
with burn injuries, from 188 in 1980 to 90 in 1990. This
suggests a decrease in burn injuries, although whether
ante- and postmortem burns were consistently differen-
tiated in those two periods is not known.
The limitations of this research include the lack of de-
tailed information available from multiple-cause-of-
death fi les and hospital data. Wiegmann and Taneja’s
( 15 ) autopsy data, collected by the FAA at the Civil
Aeromedical Institute for 44% of general aviation pilots
killed during 1996 – 1999, contains valuable detail that
was not available to us, who relied on multiple-cause-
of-death fi les. Nevertheless, as noted by Wiegmann and
Taneja ( 15 ), the fact that only 44% of pilot fatalities had
autopsy data available limits researchers’ ability to draw
meaningful conclusions from the data. Comparisons be-
tween their study and ours are diffi cult because of the
low autopsy rate in the Wiegmann and Taneja study and
because their study was limited to general aviation. Ide-
ally, all aviation deaths should result in autopsy and the
fi ndings should be part of the NTSB database.
Hospital data have limitations because coders are re-
stricted to codes available in the ICD and because details
of the crash, including airplane type, operational details,
and circumstances, may not have been available in the
medical record or may have been erroneous because
hospital personnel have to rely on others for such infor-
mation. Although it is unlikely that a person injured in
an aviation mishap would not be coded with some form
of aviation code (thus contributing to the likelihood that
the total number would be close to correct), we do not
know how accurate the specifi c coded data are. It is un-
likely that hospital coders can correctly determine, for
example, the type of operation in all cases.
Because this paper examines fatal and nonfatal
crashes, as well as aviation-related non-crashes and mis-
haps, many disparate categories of patients and opera-
tions are included. This makes it impossible to capitalize
on all of the information that may be available on each
case. On the other hand, this paper provides an over-
view of the myriad aspects of aviation and its resulting
The various military services have established highly
effective surveillance and reporting systems for all avia-
tion crashes and incidents, including the collection of
detailed medical data, data concerning the use and per-
formance of protective equipment, and detailed analysis
of the crash forces and circumstances. These data have
contributed signifi cantly to improvements in crashwor-
thiness of military aircraft over the years by providing
detailed data on crash injuries and the incidence and
causes of these injuries. These data identify where crash-
worthiness problems exist and can be used to provide
cost-benefi t analyses of proposed improvements. The
use of such data is probably best illustrated by the de-
velopment and subsequent improvements to the Army’s
UH-60 Blackhawk helicopter ( 3,11 ). Unfortunately, a
comparable system does not exist in the civil arena.
Consequently, it is diffi cult for researchers to identify
crashworthiness problems in particular aircraft or to es-
timate the magnitude of the problem or the technical
and economic feasibility of proposed improvements.
Recognizing the defi ciency in available information, the
Aerospace Medical Association passed a resolution in
2007 that standardized national databases be established
“ to record civil aircraft utilization and impact data, oc-
cupant exposure and injury data, and injury mechanism
data; which should be made readily available to safety
researchers ” ( 16 ).
This study and others have documented the inade-
quacy of injury surveillance for civil aviation crashes in
the United States and the consequences of the lack of
such data. We strongly recommend that the NTSB and/
or FAA establish a program similar to those of the mili-
tary services or similar to the National Automotive
Sampling System of the National Highway Traffi c Safety
This research was supported in part by Grants R01AA09963 and
R01AG13642 from the National Institutes of Health and by Grant
CCR302486 from the National Center for Injury Research and
Prevention, Centers for Disease Control and Prevention. We thank Ms.
Barbara Lang, B.S., for her editorial and administrative assistance.
Authors and affi liations: Susan P. Baker, M.P.H., Sc.D. (Hon.), and
Dennis F. Shanahan, M.D., M.P.H., Center for Injury Research and Policy,
Johns Hopkins Bloomberg School of Public Health, Baltimore, MD;
and Joanne E. Brady, M.S., Department of Anesthesiology, Columbia
University College of Physicians and Surgeons, and Guohua Li,
M.D., Department of Anesthesiology, Columbia University College of
Physicians and Surgeons, and Department of Epidemiology, Columbia
University Mailman School of Public Health, New York, NY.
Aviation, Space, and Environmental Medicine x Vol. 80, No. 12 x December 2009 Download full-text
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