Project Archive

SafeAmbulances was a project developed in cooperation with a grant from the National Institute of Standards and Technology (NIST).

EMS regulators face a wide range of challenges and expectations. In addition to understanding ambulance design standards, state EMS directors are often expected to be well versed in a wide range of health care issues including: interfacility transfers, hospital shortages, emerging infectious diseases, medical protocols, and medication shortages; as well as public safety issues such as inter-agency communications, homeland security, mass casualty incidents, and emergency management.

With an annual average turnover of 20%; and with 70% of state EMS directors having 5 or fewer years of experience, obtaining a working understanding of necessary information in a useful and succinct manner is essential.

For regulators seeking an understanding of how ambulance standards are developed, this page provides a high level summary of ambulance vehicle standards and links to key resources of interest.

NIOSH Video Series:
Improving EMS Worker Safety Through Ambulance Design and Testing


Map of state regulations for ambulance design standards.


EMS is one of the most dangerous jobs in the country with an injury rate about three times the national average for all occupations (Prehosp Disaster Med. 2013 Aug;28(4):376-82. doi: 10.1017/S1049023X13003555. Epub 2013 May 9).

Ambulances can be big, dangerous boxes; occasionally operated by drivers with limited experience. Ambulances weigh much more than an automobile, are more difficult to maneuver, and when responding to an emergency may operate with special privileges regarding motor vehicle laws.

Historically, while the driver’s compartment of an ambulance has been designed by automotive engineers, the patient compartment was the domain of buyers and manufacturers. In the absence state regulations referencing safety testing and standards, configuration decisions were based upon convenience and storage instead of safety.

Ambulances by design and EMS by culture have encouraged providers to be unsecured during patient transport. In the event of a sudden stop, turn, or crash, people and objects unsecured during transport become airborne and pose a threat to themselves, the patient, and others in the vehicle.


Ambulances are custom built to the buyer’s specifications, which means that everything from the number of warning lights to the position of cabinets and type of seats can be different in each ambulance.

The General Services Administration (GSA) was the government agency responsible for establishing federal standards for ambulances in 1974 and has maintained them ever since.

Ground Vehicle Standards (GVS) is a project of the Commission on Accreditation of Ambulance Services (CAAS). CAAS is an American National Standards Institute (ANSI) accredited standard development agency that specializes in ground ambulance EMS standards. GVS standards were developed by a predominately EMS centric group.

NFPA is also an ANSI accredited standard development agency with experience in developing a variety of codes and standards with a focus on responder safety. NFPA 1917: Standard for Automotive Ambulances is an ANSI accredited standard that was developed by the Technical Committee using a broad group of interested parties.

Every state has a lead agency responsible for Emergency Medical Services. In most, but not all, states, the lead EMS agency has the authority to establish the requirements for personnel, service, and vehicle licensing.

In some states licensing requirements are in the law, which can only be changed by legislative action. In other states, the requirements may be established through regulations and rules promulgated by the EMS agency or a governing board. While the latter may be more responsive in terms of contemporary changes, legislative review may also be required before adoption.

That depends on a number of factors and can range into several thousand dollars. However, by talking with the manufacturer and using their ambulance design resources, it is possible to reduce the cost by careful selection of other customized options.

The first step is to plan well in advance; like a couple of years. The process should include talking with the state EMS office about current requirements and any changes in the works. Next is reviewing the current ambulance standards and other resources that are available regarding contemporary safety.

Yes. Many manufacturers have worksheets that provide this information. Check with the local sales representatives for details.

Child restraints are not directly mentioned in J3026, GVS, or NFPA because they are covered by FMVSS 213, which is a federal standard that others cannot supersede. This means if a manufacturer is offering an integrated seat, the seat must be tested to both the SAE J3026 (adult) and FMVSS 213 (child) restraint requirements.

Regulations are a means of establishing a foundation for public trust. The majority of people calling 9-1-1 for an ambulance will only do so once in their life. It is an unplanned event where a caller reaches out for help with an expectation that those who respond are appropriately educated and equipped to assist in a safe and efficient manner. There has been considerable research conducted within the past decade that has resulted in standards that make the ambulance environment safer. Regulations should be reviewed and revised to maintain contemporary standards.

Yes. There are standards that apply to all vehicles and all compartments, such as safety restraints. Other standards apply based upon vehicles with a Gross Vehicle Weight Rating (GVWR) of more than 10,000#, which includes both Type I and Type III ambulances. Type II (van) ambulances have a GVW of between 9,201 -10,000. There is an additional classification of a Type 1 AD (Additional Duty) ambulance, which applies to vehicles with a GVWR of more than 14,001#.

No. Vehicles with a GVWR of greater than 10,000 pounds (except for school buses) are not required to be crash tested.

No. These we were removed in with revision KKK-A-1822F in 2007.

Maybe. It depends on the specific standard and the vehicle itself. Check with your sales representative or ambulance manufacturer for details.

In most states, it’s the state EMS office. Some state EMS offices have regulatory boards with rulemaking authority; others may involve the state legislature.

The current K-Specs, NFPA, and GVS standards are for new ambulances. However, remounts have been the topic of much discussion and may be included in future revisions.

This places an added responsibility on the purchaser to know the regulations in neighboring states/territories into which they may respond and/or transport.

It will also be important to have an understanding of the concurrent standards and to work with a manufacturer who adheres to an accredited ambulance standard.

Please contact your state EMS office for licensing details.

Across the country, EMS protocols are under review and undergoing changes with regard to treating patients at the scene and providers being seated and safely restrained during transport. For example, performing CPR in a moving ambulance was once the general practice. However, in many states cardiac arrest patients are now being treated at the scene – and the results suggest that this has both a better outcome for the patient and reduces the likelihood of a provider being injured during transport.

By rethinking about what a patient needs and how to provide it. For example, once upon a time, the conventional wisdom was the best way to care for a cardiac arrest was to load the patient quickly and perform one handed CPR while holding onto the ceiling rail. Today, we know that cardiac arrest survival rates are improved with high performance CPR provided at the scene. Similarly, ambulances can be configured to allow an EMS provider access to a patient and also have access to supplies and essential equipment (monitor, suction, and radio) while safely seated; facing forward, and restrained.

CPR seats and bench seats were standard configurations for decades, but crash tests by NIOSH demonstrates that both are unsafe to the provider.

Ambulances are now available with a configuration that enables an EMS provider to care for the patient, communicate with the hospital, and reach essential supplies and equipment while safely seated and restrained.

The manners in which cots/litters are secured in a vehicle have changed from the traditional antler mount to a track mount. Many ambulances also have power assisted cots that may help reduce back injuries to EMS providers.

The National EMS Safety Council (NEMSSC), a coalition of national EMS organizations, recently compiled several recommendations to encourage EMS safety practices at the agency level. The new primer, “Guide for Developing an EMS Agency Safety Program”, is intended to serve as a road map for EMS agencies to develop and implement a comprehensive safety program.

Recognizing that EMS agencies have differing levels of resources available for safety programs, the guide contains sample policies EMS agencies can adopt or readily customize to their particular agency type, size and needs. Topics addressed include roles and responsibilities of the safety officer, facility safety and security, vehicle operator safety, scene safety, infection control, personal health and safety, and patient safety. Read more and download the free guide here.

The “Star of Life” is a certification mark that was issued in 1977 to the National Highway Traffic Safety Administration. It is to be used on emergency medical care vehicles to certify that they meet Federal standards; by emergency medical care personnel to certify, based on their training and affiliation with qualified emergency medical care system, that they are authorized to provide emergency medical care; on road maps and highway signs to indicate the location of or access to qualified emergency medical care service; and such other EMS-related uses that the Administrator of NHTSA may authorize. Any other use is prohibited.

Star of Life Background, Specifications, and Criteria

Yes. NHTSA has published the Safe Transportation of Children in Ground Ambulances, which is available for download at:

The NASEMSO Safe Transportation of Children ad hoc committee has published the Safe Transport of Children by EMS: Interim Guidance and has additional information available from their website.

Changing ambulance design and manufacturing is an important step, but in many respects a greater challenge exists with improving the awareness and changing the attitude of EMS administrators, medical directors and providers.

In 2013, the American College of Emergency Physicians (ACEP) under a cooperative agreement with several federal partners developed a National EMS Culture of Safety Strategy document.

In addition, there are a growing number of articles about behavioral factors that affect EMS provider and patient safety, such as:

Teammate familiarity and risk of injury in emergency medical services. (Emerg Med J. 2015 Nov 27. pii: emermed-2015-204964. doi: 10.1136/emermed-2015-204964)

The association between weekly work hours, crew familiarity, and occupational injury and illness in emergency medical services workers. (Am J Ind Med. 2015 Dec;58(12):1270-7. doi: 10.1002/ajim.22510. Epub 2015 Aug 25)

ACEP – American College of Emergency Physicians is a professional organization that promotes high quality emergency care and is an advocate for emergency physicians, EMS providers, and their patients. ACEP provides staff and financial support for EMS Week as a public education and informational service and working with NHTSA and other federal agencies developed the EMS Culture of Safety Strategic Plan.

AMD/NTEA – AMD is a division of the National Truck Equipment Association (NTEA), a professional association with 1,800 members involved with commercial trucks, bodies, equipment, trailers, and accessories. The AMD is a division of AMD that was formed in 1976 to work closely with ambulance manufacturers and equipment suppliers.

ANSI – The American National Standards Institute, a private non-profit organization that oversees the development of voluntary consensus standards for products, services, processes, systems, and personnel in the United States.

ASTM – (ASTM International) is an organization that develops and publishes voluntary consensus technical standards for a wide range of materials, products, systems, and services. The ASTM Committee F30 on Emergency Medical Services has published standards and guides for EMS services; design construction and procurement of ambulances; EMS providers (first responder, EMT, and paramedic); and EMS Telecommunications.

CEN – the European Committee for Standardization, is an association that brings together the National Standardization Bodies of 33 European countries and provides a platform for the development of European Standards and other technical documents in relation to various kinds of products, materials, services and processes.

EMD – Emergency Medical Dispatch is a system where callers are asked specific questions to help identify what emergency resources are needed. Callers may also be given instructions while an ambulance is enroute to the scene.

FICEMS – Federal Interagency Committee on EMS was established by Congress to ensure coordination among Federal agencies supporting local, regional, state, tribal, and territorial EMS and 911 systems. Federal member agencies include the Departments of: Defense, Health & Human Services, Homeland Security, the Federal Communications Commission, and the Department of Transportation.

FMVSS – Federal Motor Vehicle Safety Standards are U.S. federal regulations specifying design, construction, performance, and durability requirements for motor vehicles and regulated Automobile safety-related components, systems, and design features.

GSA – General Services Administration. The federal agency that developed and has maintained the Federal Specification for Star-of-Life Ambulances (KKK-A-1822) since 1974. Links to these specifications is found in the Summary of Standards Development drop down box (below).

GVS – Ground Vehicle Standards, which were developed as a project of the Commission on Accreditation of Ambulance Services (CAAS). CAAS is a nonprofit organization that accredits ambulance services in North America. CAAS has established and maintained a comprehensive set of standards for ground ambulance services since 1993.

NASEMSO – The National Association of State EMS Officials is the lead national organization for EMS, a voice for national EMS policy with comprehensive concern and commitment for the development of effective, integrated, community-based, universal and consistent EMS systems.

NEMSAC – National EMS Advisory Council was established as a nationally recognized council of EMS representatives and consumers to provide advice and recommendations regarding EMS to the NHTSA and FICEMS.

NFPA – The National Fire Protection Association is an association that creates and maintains standards and codes for usage and adoption by local governments.

NIOSH – National Institute of Occupational Safety and Health Division of Safety Research (Centers for Disease Control and Prevention). The Division of Safety Research (DSR) serves as the focal point for the Institute’s traumatic occupational injury research program. The Division’s programs are organized around the public health approach to occupational injury prevention. DSR programs encompass surveillance, field investigations, analytic epidemiology, protective technology and safety engineering.

NIST – National Institute of Science and Technology (US Department of Commerce). NIST is a federal research and development agency that specializes in measurement science, such as human factor and safety elements.

NHTSA – National Highway Traffic Safety Administration. The federal agency created in 1970 to improve motor vehicle and highway safety. NHTSA’s Office of EMS works with other partners to promote a national vision for EMS with initiatives in research, education, preparedness, and safety. Considerable information is available online at the above linked website.

SAE International – Society of Automotive Engineers. SAE initially began as a a US based association and is now a global association of more than 138,000 engineers and related technical experts in the aerospace, automotive and commercial-vehicle industries.

Since the late 1800s, there have been many different designs used to transport patients to an aid station, MASH tent, or hospital. Napoleon’s physican, Dominique-Jean Larrey was the first to create a “flying ambulance” carriage staffed with a doctor, a nurse, and two attendants to bring wounded soldiers to a field first-aid center.

Since that time, the standard of care has been to have patients transported to centralized treatment centers. The design priority of the mode of transportation was on function over style, or safety. The idea of standardization was almost two centuries away.

EMS as most of us know it began in 1966, with the publication of Accidental Death and Disability; The National Disease of Modern Society by the National Academy of Sciences.

The following year, the National Academy of Sciences published the Report of a Task Force on Ambulance Services which concluded that ambulance designers must understand the role and responsibility of ambulance providers during treatment and transport. This recommendation was included in the Highway Safety Act of 1966, which required states to have highway safety standards that adhered to national performance standards.

However, ambulance designs were slow to change. In the early 1970s, the US DOT estimated that there were 28,000 ambulances, most of which were purchased with federal funds, that were not adequately configured to treat patients during transport. DOT then asked the General Services Administration (GSA) to develop standard guidelines for ambulances, which in 1974 resulted in the first publication of the Federal Specification for Star-of-Life Ambulances (KKK-A-1822, also known as K-Specs).

In the absence of other standards, the K-Specs became adopted in whole or in part by most, but not all, states as the minimum standard for state licensure. Since 1974, the K-Specs have had interim change orders and major revisions. The current version is KKK-A-1822(F), with Change Notice 14 (issued July 15, 2021).

The turn of the century saw a significant increase in the focus on ambulance safety, including:

  • In 1980, testing standards developed by AMD were incorporated into the K-Specs
  • In 2003, NIOSH completed front crash tests, working with the US and Canadian Army to test restraint systems to protect military personnel while performing their duties in moving vehicles (air and ground).
  • In 2007 NIOSH partnered with the Ambulance Manufacturers Division of the National Truck Equipment Association (AMD-NTEA) and the General Services Administration (GSA) to revise the GSA ambulance purchase specification and the companion AMD-NTEA test standards. NIOSH also worked with AMD-NTEA to establish a new crash test methodology Technical Committee. The committee used NIOSH research to develop a cost-effective test procedure to evaluate how components (seats, cot, equipment mounts) in a patient compartment would withstand a 30 mph frontal impact. (This test procedure was published by the Society of Automotive Engineers (SAE) in May of 2010 as a recommended practice, and is being used within the industry to improve ambulance seating and restraints.)

In 2008, as a result of a new project request, the National Fire Protection Association (NFPA) began the process to develop ground ambulance standards based upon the K-Specs and NFPA 1901: Standard for Automotive Fire Apparatus. The result was NFPA 1917: Standard for Automotive Ambulances, which was first published in August 2012. The current edition is 2019.

As an ANSI Standards Developer, NFPA adhered to ANSI guidelines. These guidelines include a requirement that all meetings must be open to the public and provide at least two formal opportunities for comment.

Much of the development for NFPA 1917 took place in Work Groups where interested parties focused on a specific chapter (e.g. patient compartment) to fully review each standard.  The Work Groups then reported their results to the Technical Committee on Ambulances for addition review and action. The resulting draft documents were then formally released for public comments.

The 1st edition of NFPA 1917 was approved by both the NFPA Standards Council and ANSI in August 2012.

During the development process, concerns were emerging about the impact of NFPA 1917 upon the EMS industry and the number of fire apparatus references that were incorporated into the ambulance standards. At the same time, there was an increasing body of research about ambulance safety provided by NIOSH, NIST, and SAE.

In 2013, the Commission on Accreditation of Ambulance Services (CAAS) Board of Directors discussed the impact of NFPA 1917 (1913) and established a Steering Committee to perform a detailed review.  Based upon the Steering Committee’s recommendation, the Board of Directors invited representatives from throughout the EMS industry to apply for appointment to the Ground Vehicle Standard (GVS) Action Committee.

While the GVS Action Committee was developing v.1.0, on a parallel track the CAAS Board of Directors applied to be accredited by ANSI as a Standards Developer. As such, the process used to develop GVS adhered to the ANSI process, which required all meetings to the public and include two formal public comment periods.

The GVS Action Committee sought representation throughout the EMS industry and did not have pre-established categories for membership. The Board of Directors appointed 22 voting members (primary and alternate) representing eleven EMS groups or organizations (the voting members later decreased to 20 after the IAFC withdrew their involvement). There were an additional twelve non-voting members and subject matter experts representing 6 major governmental agencies/departments.

The Action Committee worked as a group to evaluate and discuss the K-Specs in detail. This was done over the course of more than 10 two-day meetings held in the greater Washington, DC, area in addition to two formal public comment periods.

As work began on 2nd edition of NFPA 1917, there were changes made in the membership of the Technical Committee on Ambulances due to turnover within represented organizations and original members who were no longer eligible due to business mergers that took place.

The Technical Committee on Ambulances reconvened in September 2013, held meetings in several locations around the country, and provided two public comment periods. The resulting revision, NFPA 1917 (2016), was presented to at the Association Technical Meeting in June 2015. It was approved by the NFPA Standards Council in August 2015, with a Technical Interim Amendment applying to several sections. The current version, NFPA 1917 (2019) was released in 2018 with an effective date of July 1, 2019.

The CAAS Board of Directors also appointed a GVS Consensus Body who received and reviewed the recommendation from the GVS Action Committee. Membership in the Consensus Body again solicited throughout the EMS industry provided that there was no crossover to Action Committee members. There were eighteen members appointed to the Consensus Committee.

CAAS was accredited by ANSI in October 2015, and published Ground Vehicle Standards V1.0 in 2016. The current version, Ground Vehicle Standards V2.0 went into effect July 1, 2019.

GVS is on a three-year revision cycle;  NFPA 1917 is on a five-year revision cycle.

For More Information

Jay Bradshaw
Project Advisor