Objectives:​ Earlier research has shown that the rear row is safer for occupants in crashes than the front row, but there is evidence that improvements in front-seat occupant protection in more recent vehicle model years have reduced the safety advantage of the rear seat versus the front seat. The study objective was to identify factors that contribute to serious and fatal injuries in belted rear-seat occupants in frontal crashes in newer model year vehicles.

Methods:​ A case series review of belted rear-seat occupants who were seriously injured or killed in frontal crashes was conducted. Occupants in frontal crashes were eligible for inclusion if they were 6 years old or older and belted in the rear of a 2000 or newer model year passenger vehicle within 10 model years of the crash year. Crashes were identified using the 2004–2015 National Automotive Sampling System Crashworthiness Data System (NASS CDS) and included all eligible occupants with at least one AIS 3 or greater injury. Using these same inclusion criteria but split into younger (6 to 12 years) and older (55+ years) cohorts, fatal crashes were identified in the 2014– 2015 Fatality Analysis Reporting System (FARS) then local police jurisdictions were contacted for complete crash records.

Results:​ Detailed case series review was completed for 117 rear-seat occupants:​ 36 with MAIS 3+ injuries in NASS CDS and 81 fatalities identified in FARS. More than half of the injured and killed rear occupants were more severely injured than front occupants in the same crash. Serious chest injury, primarily caused by seat belt loading, was present in 22 of the injured occupants and 17 of the 37 fatalities with documented injuries. Nine injured occupants and 18 fatalities sustained serious head injury, primarily from contact with the vehicle interior or severe intrusion. For fatal cases, 12 crashes were considered unsurvivable due to a complete loss of occupant space. For cases considered survivable, intrusion was not a large contributor to fatality.

Discussion:​ Rear-seat occupants sustained serious and fatal injuries due to belt loading in crashes in which front-seat occupants survived, suggesting a discrepancy in restraint performance between the front and rear rows. Restraint strategies that reduce loading to the chest should be considered, but there may be potential tradeoffs with increased head excursion, particularly in the absence of rear-seat airbags. Any new restraint designs should consider the unique needs of the rear-seat environment.