Public Hearing on Truck & Bus Safety, April 14-16, 1999

April 1986 Safety Study:

Training, Licensing, and Qualification Standards for Drivers of Heavy Trucks

An April 1986 National Transportation Safety Board safety study, based on major tractor-semitrailer accident investigations in 1981, 1982, and 1984, came to 23 conclusions, including:

· Some truckdriving training schools did not provide adequate instruction, there was no system to evaluate school training and no Federal requirement for drivers of heavy trucks to receive formal training, and no nationally organized truckdriver apprenticeship training program had been set by labor and management.

· Licensing standards differed substantially among States, knowledge and performance tests for licenses were inadequate in many States, many States did not require retests for license renewals, and procedures allowed drivers to often obtain more than one license at a time from different States enabling the driver to hide traffic violations.

· Federal motor carrier safety regulations had too many exemptions and were unclear and inadequate in many areas, including driver disqualification standards, driver background checks, motor carrier annual driver record reviews, driver examination, and medical qualifications and examinations.

Recommendations: The Safety Board issued 30 recommendations to the following recipients: Secretary of Transportation (H-86-8 and -9); American Association of Motor Vehicle Administrators (H-86-10 and -11); American Insurance Association, Alliance of American Insurers, National Association of Independent Insurers, and Insurance Services Office (H-86-12); American International Group Transport and Canal Insurance Co. (H-86-13); Professional Truck Driver Institute (H-86-14 and -16); National Safety Council (H-86-17); American Trucking Associations, Inc., (H-86-18 through 20); Private Truck Council of America (H-86-21 and -22); Owner-Operator Independent Drivers Association of America and National Association of Truck Driving Schools (H-86-23); International Brotherhood of Teamsters (H-86-24 and -25); Department of Labor (H-86-26); Federal Highway Administration (H-86-27 through -34); and National Highway Traffic Safety Administration (H-86-35 through -37). The Safety Board reiterated two recommendations to the Bureau of Motor Carrier Safety (H-83-21) and Federal Highway Administration (H-83-68).

Intercity Tour Bus Loss of Control and Rollover into River
Walker, California: 21 Killed, 20 Injured

At about 10:10 a.m. on May 30, 1986, a southbound intercity charter bus operated by Starline Sightseeing Tours went out of control while negotiating an S-curve on U.S. Route 395 about 11 miles south of Walker, California. The bus crossed the centerline, swerved back and forth several times, hit a rock fence, crossed into the northbound lane and overturned, landing on its roof in the West Walker River. Twenty-one passengers were killed; the driver and 19 passengers were injured.

Probable Cause: The failure of the charter busdriver to comply with highway speed limits and advisory speed signs and to reduce the bus speed sufficiently to negotiate safely the S-curve on U.S. Route 395. Contributing to the accident was the inadequate screening and supervision of the busdriver by the motor carrier.

Dissent: Board Member Burnett filed a dissent saying that he believed the driver's failure to apply his service brakes during the accident sequence may have resulted from his being tired because of his extended duty time before the accident and that fatigue cannot be ruled out as an accident factor.

Recommendations: The Safety Board issued three recommendations to the following recipients: Federal Highway Administration (H-87-36 and -37) and Department of Transportation (H-87-38). The Board reiterated one recommendation to the Federal Highway Administration (H-80-16).

Public Hearing: The Safety Board held a public hearing in Sparks, Nevada, on September 23 and 24, focusing on the main safety issues in the investigation.

Intercity Bus Collision with Truck on Interstate Highway
Brinkley, Arkansas: 28 Injured

On July 14, 1986, at 4:15 a.m., a tractor-semitrailer combination, operated by Rising Fast Trucking Company, was making a U-turn at a highway crossover on I-40 near Brinkley, Arkansas, when it was struck by an eastbound intercity bus operated by Trailways Lines. The truckdriver, codriver, and one bus passenger were uninjured. The busdriver and 27 passengers sustained injuries ranging from minor to serious.

Probable Cause: The attempt by the driver of the Rising Truck Company vehicle to execute an illegal U-turn at a highway crossover. Contributing to the severity of the accident was the operation of the Trailways intercity bus at a speed which did not permit adequate time and distance to slow or stop the bus to avoid the collision.

Recommendations: The Safety Board issued three recommendations to the following recipients: Federal Highway Administration (H-87-45),Governor and Arkansas General Assembly (H-87-46), and American Trucking Associations (H-87-47).

Charter Bus/Tractor-Semitrailer Rearend Collision
Carney's Point, New Jersey: 39 Injured

About 7:30 a.m. on September 29, 1986, a Leatherwood Motor Coach Corp. charter bus carrying 38 passengers was traveling northbound on I-295 near Carney's Point, New Jersey, en route to Atlantic City, New Jersey. After passing three tractor-semitrailers in the left lane, the bus moved into the right lane and struck the rear of another slow moving tractor-semitrailer. Two bus passengers were seriously injured, and five were moderately injured. The busdriver and 31 bus passengers received minor injuries.

Probable Cause: The busdriver's inattention to his driving task and misjudgment of the closing speed between the bus and truck in front of him. Contributing to the accident was the motor carrier's failure to adequately screen the busdriver's qualifications and background. Contributing to the severity of the injuries was the high speed of the bus.

Recommendations: The Safety Board issued three recommendations to the following recipients: Federal Highway Administration (H-87-39), Leatherwood Motor Coach Corp. (H-87-40), and United Bus Owners of America and American Bus Association (H-87-41).

Multiple Collision with Charter Bus, Passenger Car, and Transit Bus
North Bergen, New Jersey: 1 Killed, 26 Injured

About 7:34 a.m. on October 9, 1986, two charter intercity tour buses carrying European tourists were traveling westbound in the right lane on State Route 495 in North Bergen, New Jersey, en route to Washington, D.C. As the buses approached an exit, the second bus veered leftward into the adjacent lane, struck a passenger car, then crossed into the eastbound contraflow lane and struck a transit bus with passengers en route to New York City. One transit bus passenger was killed, and 26 occupants of both buses sustained serious to minor injuries.

Probable Cause: The distraction of the charter busdriver from his driving duties while assisting a bus passenger with a CB radio that resulted in his failure to remain within the proper traffic lane while traveling in a construction zone.

Recommendations: The Safety Board issued three recommendations to the following recipients: E. Vanderhoff and Sons Bus Co. (H-87-55), DeCamp Bus Lines (H-87-56), and the New Jersey Department of Transportation (H-87-57).

Public Hearing: The Safety Board held a public hearing in Secaucus, New Jersey, on February 11, 1987, focusing on the main safety issues in the investigation.

May 1987 Accident Report:

Tractor-Semitrailer and Intercity Bus Head-On Collision on Interstate Highway
Beaumont, Texas: 6 Killed, 19 Injured

About 1:45 p.m. on May 4, 1987, while traveling eastbound on I-10 in Beaumont, Texas, a tractor-semitrailer operated by Graebel Van Lines jackknifed in the center lane, veered leftward across the left lane and median strip, and struck a Trailways bus traveling westbound in the left lane. It was raining. The busdriver and 5 bus passengers were killed, 17 bus passengers sustained serious to minor injuries, and 6 bus passengers were uninjured. The truckdriver and helper received minor injuries.

Probable Cause: The truckdriver's operation of a tractor-semitrailer at a speed too great for existing weather conditions while traveling on a section of lightly flooded highway pavement. Contributing to the loss of control of the tractor-semitrailer was the inadequate tread depth of the rear tractor tires, inoperable speedometer on the truck, low surface texture of the pavement, low friction of the lightly flooded pavement, and improper corrective maintenance of the highway.

Recommendations: The Safety Board issued six recommendations to the following recipients: Federal Highway Administration (H-88-1 and -2), bus manufacturers (H-88-3), United Bus Owners of America and American Bus Association (H-88-4 and -5), American Trucking Associations (H-88-5), and Graebel Van Lines (H-88-6). The Board reiterated one recommendation to the Texas Department of Highways and Public Transportation (H-87-2).

School Bus and Truck Collision
Bronson, Florida: 6 Killed, 17 Injured

At 2:50 p.m. on August 28, 1987, a 1982 school bus operated by the School Board of Levy County, Florida, transporting 2 adult aides and 19 special education students, was traveling westbound on County Road 32 near Bronson, Florida, when it collided with an Airdrome Tire Centers two-axle flatbed truck. The truck was traveling northbound on County Road 337. The weather was clear, and the pavement was dry. The school busdriver and five passengers were killed. The truckdriver sustained critical injuries, and 16 school bus passengers were injured.

Probable Cause: The truckdriver's failure, for undetermined reasons, to stop his vehicle at the stop sign. Contributing to the severity of the accident was the speed of the truck and the loss of structural integrity of the school bus because of the collapse of the school bus floor.

Recommendations: The Safety Board issued two recommendations to the following recipients: National Highway Traffic Safety Administration (H-89-20) and the Governor and General Assembly of Florida (H-89-21).

Intercity Bus Run-off-Road and Overturn
Middletown, New Jersey: 2 Killed, 32 Injured

At 5:00 a.m. on September 6, 1987, an intercity bus operated by Academy Lines ran off the northbound local lane of the New Jersey Garden State Parkway near Middletown, New Jersey, struck a guardrail and bridge rail, and overturned onto its right side. The busdriver and one passenger, the busdriver's 13-year-old son, were killed. Thirty-two of the remaining 33 passengers received minor to moderate injuries.

Probable Cause: The busdriver's lack of vigilance, which resulted in his failure to perceive that his vehicle was leaving the roadway. The busdriver's lack of vigilance resulted from the combined adverse effects of sleep deprivation, illness due to a cold or influenza, and a high dosage of medication probably ingested to treat the symptoms of that illness and to control his weight.

Recommendations: The Safety Board issued two recommendations to the following recipients: Federal Highway Administration (H-88-24) and the New Jersey Highway Authority (H-88-25). The Board reiterated one recommendation to the Federal Highway Administration (H-85-20).

July 1988 Accident Report:

Intercity Bus Loss of Control and Highway Run Off
Little Egg Harbor Township, New Jersey: 41 Injured

About 12:29 p.m. on July 23, 1988, a chartered Gray Line intercity bus carrying the driver and 44 passengers en route to Atlantic City, New Jersey, was traveling southbound in the left lane of the New Jersey Garden State Parkway. About 20 miles from Atlantic City, the bus left the highway and traveled 380 feet along a sloping grassy median, sideswiped several bushes and trees, and came to rest against standing trees 40 feet from the roadway. The bus remained upright, and no other vehicles were involved in the accident. Forty passengers and the busdriver sustained minor to severe injuries.

Probable Cause: The busdriver's impairment from the recent use of cocaine while on duty that resulted in the loss of control of the vehicle.

Recommendations: None because accident issues were covered in previous recommendations.

Case Summaries of 189 Heavy Truck Accident Investigations

An October 1988 Safety Board safety study found that the actions of truckdrivers probably have a greater influence on accidents than any other factor. It outlined 11 issues stemming from 189 accident investigations, including:

· Repeated violations of Federal hours-of-service regulations. Many drivers investigated participated in off-duty activities that may have left them fatigued even before reaching the limits of the duty time allowed. It was not uncommon to find multiple logbooks falsely indicating compliance with regulations.

· As in its 1986 truck study, the Safety Board again emphasized that there were no Federal training prerequisites for interstate driving, although the U.S. Department of Transportation had initiated rulemaking.

· Drivers impaired by alcohol, drugs, or a combination of the two unfailingly demonstrated poor driving judgment.

· In many cases, the Safety Board found very poor driving records, suspended or revoked operators' licenses, or multiple licenses. Some motor carriers were aware of drivers' past records; some drivers failed to report disqualifying past history to their employer.

· Practices of motor carriers, including inadequate oversight and failure to follow safety regulations, contributed either directly or indirectly to many of the investigated accidents.

· The Board believes that drivers responsible for the transportation of hazardous materials should be the elite of their class. The study found drivers of hazardous cargoes who were impaired by alcohol or drugs or both, fatigued drivers, poorly maintained equipment, and some carriers of hazardous materials in total noncompliance of with safety rules.

Recommendations: None from this study because recommendations related to this study's findings were issued as result of other accidents and studies.

Intercity Bus Loss of Control and Overturn on Interstate Highway
Nashville, Tennessee: 39 Injured

About 6:45 a.m. on November 19, 1988, an intercity bus operated by Greyhound Lines with 45 occupants, traveling southbound through a construction zone on I-65 in Nashville, went out of control during a steering maneuver in heavy rain. The bus rotated 190 degrees and came to rest facing northbound on the southbound embankment. The unrestrained busdriver and 38 passengers sustained serious to minor injuries.

Probable Cause: The operation of the bus at a speed that was above the regulatory limit and too great for existing weather conditions that resulted in the driver's loss of control. Contributing to the loss of control was the variant frictional properties of the travel lanes in the construction zone.

Recommendations: The Safety Board issued eight recommendations to the following recipients: Greyhound Lines (H-89-26 through -30), the Federal Highway Administration (H-89-31 and -32), and the Tennessee Department of Transportation (H-89-33).

Braking Deficiencies on Heavy Trucks in 32 Selected Accidents

A November 1988 Safety Board safety study, based on 32 of 189 investigated accidents in 29 States from 1985 through 1987, came to 11 conclusions, including:

· Poorly maintained, malfunctioning, or totally inoperative brakes were a significant problem on at least 32 trucks involved in the 189 accidents. The most prevalent braking deficiency was brakes out of adjustment.

· Among accident-involved carriers, it was often unclear who was responsible for on-the-road brake adjustment. Some drivers responsible for brake adjustment had not been trained to adjust truck brakes properly.

· More widespread use of automatic slack adjusters would reduce the incidence of out-of-adjustment brakes. Airbrake actuation devices that incorporate indicators to warn users of brake adjustment would make it easier to know when to adjust brakes without automatic slack adjusters and might reduce the incidence of out-of-adjustment brakes.

Recommendations: The Safety Board issued three recommendations to the following recipients: National Highway Traffic Safety Administration (H-88-30); American Trucking Associations, Inc., (H-88-31 and -32); and National Private Truck Council (H-88-31-32).

Intercity Bus Loss of Control and Overturn on Interstate
Tinton Falls, New Jersey: 50 Injured

About 11:25 a.m. on November 29, 1988, a chartered Leisure Line intercity bus carrying a driver and 49 passengers en route to Atlantic City, New Jersey, was traveling southbound on the Garden State Parkway near Tinton Falls, New Jersey. The bus, without signaling, veered rightward of the travel lane, sideswiped a guardrail, skidded back onto the highway, overturned onto its right side, and slid abut 220 feet diagonally across two express lanes before coming to rest with the rear of the bus across half of the left travel lane. The busdriver said he did not apply the service brakes before or during the accident sequence. The busdriver and 49 passengers sustained minor to severe injuries.

Probable Cause: The busdriver's inattention that resulted in the loss of control of his vehicle.

Recommendations: The Safety Board issued five recommendations to the following recipients: Leisure Time Bus Lines (H-89-15), United Bus Owners of America and American Bus Association (H-89-16), National Highway Traffic Safety Administration (H-89-17), New Jersey Department of Transportation (H-89-18), and Federal Highway Administration (H-89-19).

September 1989 Accident Report:

Collision Between School Bus and Tractor-Semitrailer
Alton, Texas: 21 Killed, 49 Injured

About 7:34 a.m. on September 21, 1989, a westbound school bus carrying 81 students operated by the Mission Consolidated Independent School District, Mission, Texas, and a northbound delivery truck operated by Valley Coca-Cola Bottling Co., collided at Bryan Road in Alton, Texas. The truck came to rest facing west on the right hand shoulder. The school bus continued in a northwest direction and dropped about 24 feet into an excavation pit partially filled with water. The bus came to rest on its left side facing southeast, totally submerged in about 10 feet of water, about 35 feet from the shoreline. The bus front boarding door was jammed shut, but the rear emergency exit door was operable. No other emergency exits were on the bus. Twenty-one students died as a result of drowning or complications related to submersion. Forty-nine occupants, including the bus- and truckdrivers, sustained injuries.

Probable Cause: The truckdriver's inattention and subsequent failure to maintain sufficient control of his vehicle to stop at the stop sign. Contributing to the severity of the accident was the lack of a sufficient number of emergency exits on the school bus to accommodate the rapid egress of all 81 students.

Dissent: Board Member Burnett concurred with the probable cause but would have added, "contributing to the severity of the accident was the deficient condition of the truck's brakes." He said he voted not to adopt the report because the report dealt inadequately with the performance of the brakes in the Coca-Cola truck and its effect on the accident scenario.

Recommendations: The Safety Board issued 17 recommendations to the following recipients: National Highway Traffic Safety Administration (H-90-74 through -78), Texas Department of Public Safety (H-90-79 and -80), Texas Education Agency (H-90-81), Hidalgo County (H-90-82 and -83), City of Alton (H-90-84 and -85), Mission Consolidated Independent School District (H-90-86), Coca-Cola Enterprises (H-90-87), Valley Coca-Cola Bottling Company (H-90-88 and -89), and National Association of State Directors of Pupil Transportation (H-90-90). The Board reiterated one recommendation to the National Highway Traffic Safety Administration (H-89-5).

February 1990 Safety Study:

Fatigue, Alcohol, Drugs, and Medical Factors
In Fatal Heavy Truck Driver Crashes

A February 1990 Safety Board safety study, based on 186 heavy truck accident investigations in 8 States during the 1988 fiscal year, in which the driver was killed, came to 34 conclusions, including:

· Based on toxicological tests, 33 percent of fatally injured drivers tested positive for alcohol and other drugs of abuse. The most prevalent drugs found were marijuana and alcohol (13 percent each) followed by cocaine (9 percent), methamphetamine/amphetamines (7 percent), and other stimulants.

· Fatigue and fatigue-drug interactions were involved in more fatalities than alcohol and other drugs of abuse alone.

· There was a strong association between violation of Federal hours-of-service regulations and drug usage; drivers with at least one suspended or revoked license were more likely to have used drugs of abuse.

· A disproportionately high percentage of drivers who used drugs were single, separated, or divorced.

· The driver's medical condition caused or contributed to 10 percent of the accidents. Over 90 percent of medical condition-related accidents involved some form of cardiac incident.

· Older drivers were less likely to have tested positive for drugs but were more likely to have had an incapacitating medical incident.

· Occupant protection issues were the most frequently identified noncausal factors involved in a heavy truck fatal accident (68 of 185). In 62 percent of the accidents, some management deficiency in oversight of the driver or in the proper condition of the vehicle was identified. Deficiencies in both were identified in 18 percent.

· There was a significant relationship between drug positive test results and the type of trucking service. Nearly 42 percent of fatally injured truckload drivers tested positive compared with 14 percent of less-than-truckload drivers.

Recommendations: The Safety Board issued 46 recommendations to the following recipients: Department of Transportation (H-90-10 through -15); National Highway Traffic Safety Administration (H-90-16); Federal Highway Administration (H-90-17 through -32); Department of Health and Human Services (H-90-33 and -34); American Trucking Associations, Inc., Regular Common Carrier Conference, Private Carrier Conference, National Private Truck Council, Owner-Operator Independent Drivers Association, Shippers National Freight Claim Council, and International Brotherhood of Teamsters (H-90-35 through -37); Commercial Vehicle Safety Alliance (H-90-35 through -39); International Association of Chiefs of Police and International Association of Directors of Law Enforcement Training and Standards (H-90-38 and -39); National Governors Association (H-90-40 and -41); Governors of 50 States, Puerto Rico, Virgin Islands, and U.S. Territories (H-90-42 through -54); and National Association of Trade and Technical Schools, National Home Study Council, and Professional Truck Driver Institute of America (H-90-55).

Multiple Vehicle Collision and Fire in Work Zone on Interstate
Sutton, West Virginia: 8 Killed, 2 Injured

About 5:40 p.m. on July 26, 1990, a truck operated by Double B Auto Sales, transporting eight automobiles, entered a highway work zone on northbound I-79 near Sutton, West Virginia, and struck the rear of a utility trailer being towed by a passenger car. The car then struck the rear of another passenger car, and the Double B truck and the two automobiles traveled into the closed right lane and collided with West Virginia Department of Transportation maintenance vehicles. Fire ensued. Eight occupants of the two cars were killed. The truckdriver and a firefighter sustained minor injuries.

Probable Cause: The inattention of the driver of the Double B Auto Sales truck due to fatigue and exacerbated by an inadequate and unbalanced diet the day of the accident and the inadequacy of the oversight exercised by Double B Auto Sales to ensure that its drivers were qualified and received adequate rest. Contributing to the cause of the accident was the less than optimal work zone control devices and procedures used by the West Virginia Department of Transportation. Contributing to the severity of the accident was the operation of the Double B vehicle at a speed in excess of the posted limit, creating a speed differential between the Double B truck and the other involved vehicles, and the Double B truckdriver's failure to properly secure the automobiles being transported on his vehicle's head ramp.

Recommendations: The Safety Board issued 18 recommendations to the following recipients: Double B Auto Sales (H-91-14), West Virginia Department of Transportation (H-91-15 through -21), State of New York (H-91-22 through -25), National Automobile Transporter's Association (H-91-26), and Federal Highway Administration (H-91-27 through -31).

February 1991 Accident Report:

Overturn of Gasoline Tractor-Semitrailer and Fire
Carmichael, California: 3 Injured

About 3 a.m. on February 13, 1991, a tractor-semitrailer cargo tank overturned as the vehicle was traveling on a main urban roadway in Carmichael, California. The tractor and semitrailer were owned and operated by Calzona Tankways, Phoenix, Arizona. The truck was being used for intrastate delivery of gasoline to service stations, and the cargo tank contained about 8,800 gallons of automotive gasoline. The driver lost control of the vehicle on a curve, and it turned onto its side and struck the embankment of a drainage ditch. The rear end of the cargo tank landed on an unoccupied car in the field. Gasoline from the cargo tank spilled into the ditch and ignited, engulfing the truck and car. The gasoline spread the fire to the nearby area destroying or heavily damaging two more cars and four homes. Three people received minor injuries.

Probable Cause: The inattention of the driver, for undetermined reasons, which resulted in his operation of the tank truck at excessive speed leading to its overturning. Contributing to the severity of the accident was the failure of one of the liquid-level sensors mounted on the manhole cover for the forward compartment of the cargo tank to remain secured.

Recommendations: The Safety Board issued seven recommendations to the following recipients: Federal Highway Administration (H-91-32 and -33), Research and Special Programs Administration (H-91-34), National Highway Traffic Safety Administration (H-91-35), State of California (H-91-36), 50 states and District of Columbia (H-91-37), and Calzona Tankways (H-91-38).

Reducing Fog-Related Highway Accidents
Knoxville, Tennessee

On April 24 and 25, 1991, the Safety Board held a public hearing in Knoxville, Tennessee, to discuss ways to reduce fog-related highway accidents. The hearing stemmed from four multiple vehicle collisions in Tennessee, Utah, and California in late 1990 and early 1991, which involved 238 vehicles, with 21 deaths and 90 injuries. Issues explored at the hearing included heavy truck and small vehicle mix in fog conditions, countermeasures to deal with highway fog conditions, adequacy of Federal and State fog policies, fog sensing devices and highway user system warning devices, and driver perception and reaction to fog.

Intercity Bus Run-Off-Road
Donegal, Pennsylvania: 1 Killed, 15 Injured
Caroline, New York: 34 Injured

Donegal: About 1:50 p.m. on June 26, 1991, an intercity bus operated by Greyhound Lines was traveling eastbound on the Pennsylvania Turnpike en route to Washington, D.C. from Cleveland, Ohio. About 7 miles beyond the Donegal exit, the bus passed a passenger car, then crossed into the right lane in front of a semitrailer, ran off the right side of the roadway down a 100-foot embankment, and overturned onto its right side. One passenger was killed; the driver and 14 passengers were injured.

Caroline: About 6:45 a.m., on August 3, 1991, an intercity bus operated by Greyhound Lines was traveling westbound on Star Route 79 en route to Ithaca, New York. About 10 miles east of Ithaca, the bus began to drift leftward and ran off the right side of the roadway into a drainage ditch. The bus traveled along the ditch about 500 feet, went back on the roadway, rotated 180 degrees clockwise, went back off the right side of the roadway, and overturned onto its left side facing east. The driver and 33 passengers were injured.

Probable Cause: The failure of Greyhound Lines to ensure that the busdrivers had adequate training and experience to operate intercity buses safely, resulting in their inability to control their vehicles, which ran off the road and overturned.

Recommendations: The Safety Board issued six recommendations to the following recipients: Greyhound Lines (H-92-13 through -17) and the Department of Labor (H-92-18).

Tour Bus Plunge from Road and Overturn
Palm Springs, California: 7 Killed, 47 Injured

At 3:24 p.m. on July 31, 1991, a school bus operated by Mayflower Contract Services was traveling eastbound on undivided, two-lane Tramway Road from the Palm Springs, California, aerial tramway parking lot. On board the bus were 45 girl scouts and 8 adult advisors on a sightseeing trip. During the descent, the bus increased speed, left the road, plunged down an embankment, and collided with several large boulders. The busdriver and 6 passengers were killed; 47 passengers were injured.

Probable Cause: The loss of speed control while descending Tramway Road because of the busdriver's use of improper driving techniques for mountainous terrain. Contributing to the accident was the out-of-adjustment brakes, which had not been detected in the Mayflower Contract Services maintenance reporting and inspection procedures.

Recommendations: The Safety Board issued 17 recommendations to the following recipients: Federal Highway Administration (H-93-10 and -11), State of California (H-93-12 and -13), California Department of Education (H-93-14 and -15), California Highway Patrol (H-93-16 and -17), Mount San Jacinto Winter Park Authority (H-93-18), National Committee on Uniform Traffic Laws and Ordinances (H-93-19), American Association of State Highway and Transportation Officials (H-93-20), National Association of State Directors of Pupil Transportation Services (H-93-21 and -22), Allison Transmission Division (H-93-23), and Mayflower Contract Services (H-93-24 through -26).

Public Hearing: On October 31 and November 1, 1991, the Safety Board held a public hearing as part of its investigation into the July 1991 fatal school bus accident in Palm Springs, California, that killed 7 and injured 47 people. The public hearing in Los Angeles focused on the busdriver's training and knowledge of bus features, adequacy of the bus company's inspection and maintenance program, safety features of private roads open to the public, and the advisability of installing lap belts in school buses.

February 1992 Special Investigation:

Hazardous Materials Cargo Tank Rollover Protection

A February 1992 special investigation, based on seven highway accidents in which bulk liquid cargo tanks overturned and released hazardous materials, came to nine conclusions, including:

· Insufficient guidance from the Research and Special Programs Administration about factors and assumptions that a cargo tank manufacturer must consider when calculating the loads on rollover protection devices and protection and shielding of top-mounted fittings on bulk liquid cargo tanks.

· Inadequate information about forces that can be encountered in a rollover accident and the extent to which rollover protection devices can be reasonably designed to withstand these forces because the Research and Special Programs Administration, Federal Highway Administration, and the industry had not provided engineering modeling or analysis to determine the magnitude of forces acting on cargo tanks during different accident conditions.

· Federal Highway Administration inspectors were not trained, qualified, or directed to evaluate loading calculations or to determine if rollover protection devices on cargo tanks had been designed and built to U.S. Department of Transportation specifications.

· The Federal Highway Administration did not adequately exercise enforcement responsibilities pertaining to the design and construction of U.S. Department of Transportation specification cargo tanks.

· The Federal Highway Administration and the Research and Special Programs Administration accident databases were not adequate to identify important trends or potential problems related to the design and construction of bulk liquid cargo tanks.

Recommendations: The Safety Board issued 12 recommendations to the following recipients: Research and Special Programs Administration (H-92-1 through -6) and Federal Highway Administration (H-92-7 through -12).

Heavy Vehicle Airbrake Performance

An April 1992 Safety Board safety study, based on brake-related accidents involving heavy trucks and an extensive program to inspect heavy trucks in five States, came to 24 conclusions, including:

· Available data did not allow braking deficiencies to be readily evaluated; however, the Safety Board investigations suggested that deficient brakes on heavy vehicles were a factor in more accidents than statistics showed.

· In 9 of 15 brake-related accidents, State and local investigating agencies failed to identify deficient brakes as a factor in their final reports.

· Federal regulations did not adequately address stability under variant load and road conditions and stopping situations at speeds of over 20 mph and did not specify stopping distance or within-lane stability requirements.

· Maintenance deficiencies in the accident vehicles' brake systems degraded stopping capability and directional stability, many carriers did not have adequate policies for brake inspection and adjustment intervals, and brake maintenance literature presented various methods of proper adjustment but no universally accepted brake adjustment procedures existed.

· Of 1,520 five-axle heavy trucks inspected, 56.3 percent were placed out of service due to brake system violations, including 46.1 percent for brake adjustment deficiencies. Of the manual slack adjusters checked, 26 percent were found at or past the manufacturer's recommended adjustment limit, while 15 percent of the automatic adjusters were at or past the limit.

· Full-scale brake block testing procedures and consistent brake block effectiveness ratings were needed so appropriate brake lining materials could be selected.

· An antilock braking system could have prevented all six of the instability-related accidents simulated for the study.

Recommendations: The Safety Board issued 35 recommendations to the following recipients: National Highway Traffic Safety Administration (H-92-50 through -55); Federal Highway Administration (H-92-56 through -59); 50 States, District of Columbia, Puerto Rico, Virgin Islands, and U.S. Territories (H-92-60 through -62); Interstate Towing Association and Towing and Recovery Association of America (H-92-63); National Private Truck Council (H-92-64 through -68); Owner-Operator Independent Drivers Association (H-92-69 through -73); American Trucking Associations (H-92-74 through -78); Motor Vehicle Manufacturers Association (H-92-79 and -80); Professional Truck Driver Institute of America (H-92-81); Society of Automotive Engineers (H-92-82); and airbrake component manufacturers (H-92-83 and -84).

Charter Bus Loss of Control and Fire
Vernon, New Jersey: 6 Killed, 40 Injured

About 11:10 a.m. on July 26, 1992, a charter bus, owned and operated by Sensational Golden Sons Bus Service, was en route from Brooklyn, New York, to an amusement park in Vernon, New Jersey. Control of the bus was lost as it descended a steep hill. The bus struck a car, overturned on its right side, slid and spun on its side, uprighted, and struck another car before coming to rest. A fire ensued, burning the bus and the second car. Twelve passengers were ejected from the bus during the collision, and six of them were killed. The busdriver and the 37 other bus passengers sustained minor to serious injuries. The two car drivers sustained minor injuries.

Probable Cause: The busdriver/owner's failure to maintain the bus adequately and his deliberate disregard in choosing to operate the bus with known brake deficiencies. Contributing to the accident was the failure of the New York Department of Transportation to inspect the bus and ensure that its deficiencies were corrected. Also contributing to the accident was the inadequacy of the Federal Highway Administration's system for identifying motor carriers.

Recommendations: The Safety Board issued seven recommendations to the following recipients: Federal Highway Administration (H-93-27 and -28), New York State Department of Motor Vehicles (H-93-29), New York Department of Transportation (H-93-30), American Association of Motor Vehicle Administrators (H-93-31), United Bus Owners of America (H-93-32), and American Bus Association (H-93-33).

Public Hearing: On October 21 and 22, 1992, the Safety Board held a public hearing in Secaucus, New Jersey, on certification of charter buses and inspection requirements for charter bus companies. The hearing stemmed from the July 1992 charter bus accident in Vernon, New Jersey, that killed 6 passengers and injured all 40 others. The hearing also focused the signing and design of the roadway approaching the bus accident site.

Wheel Separation in Medium and Heavy Trucks

A September 1992 special investigation, based on five truck-wheel runoff accidents, came to 10 conclusions, including:

· Wheel separation accidents constitute about 0.3 percent of all truck accidents; the leading causes of wheel separations from medium to heavy trucks are improper tightening of wheel fasteners and bearing failure, both the result of inadequate maintenance.

· Federal and State oversight of wheel inspections and recalls appeared to be adequate; however, most Federal and State reporting forms do not differentiate between tire and wheel failures.

· Trucking industry lacked uniform model guidelines for maintenance and inspection of all types of medium to heavy trucks, and the industry did not have a uniform recommended practice that specifies how often wheel bearings should be inspected.

· Undertightening of wheel fasteners usually resulted from the failure to follow recommended wheel maintenance practices; overtightening more easily resulted from an air impact wrench instead of a torque wrench.

Recommendations: The Safety Board issued six recommendations to the following recipients: American Trucking Associations, National Wheel and Rim Association, Motor Vehicle Manufacturers Association, Truck Trailer Manufacturers, and Society of Automotive Engineers (H-92-98 through -101); Federal Highway Administration (H-92-102); and Department of Transportation (H-92-103).

March 1993 Accident Report:

Tank Truck-Passenger Train Collision and Fire
Ft. Lauderdale, Florida: 6 Killed

At 3:13 p.m. on March 17, 1993, an Amerada Hess tractor-semitrailer hauling gasoline was struck by Amtrak passenger train 91. The truckdriver was attempting to cross a railroad-highway grade crossing at Cypress Creek Road in Fort Lauderdale, Florida. Traffic in the area of the crossing was congested because the left and center lanes were closed just over the crossing. Traffic was being channeled into the right lane and later shifted into a right-turn lane. The truck, which was loaded with 8,500 gallons of gasoline, was punctured when it was struck. A fire erupted, engulfing the truck and nine other vehicles. The fire killed the truckdriver and five occupants of three stopped vehicles.

Probable Cause: The inadequacy of the precautions taken by the Broward County project manager, the design engineer, and the contractor, which resulted in traffic congestion at the railroad-highway grade crossing, and the truckdriver's decision to cross the railroad track even though the warning system had been activated.

Recommendations: The Safety Board issued four recommendations to the following recipients: Federal Highway Administration (H-94-1 and -2), American Trucking Associations (H-94-3), and Amerada Hess Corporation (H-94-4).

Tractor-Trailer Semitrailer Collision with Interstate Bridge
Evergreen, Alabama: 2 Killed, 1 Injured

At 1:35 a.m. on May 19, 1993, while traveling south on I-65 near Evergreen, Alabama, a tractor with bulk-cement-tank semitrailer left the paved road, traveled along an embankment, overran a guardrail, and collided with a supporting bridge column of the County Road 222 overpass. Two spans of the overpass collapsed onto the semitrailer and the southbound lanes of the interstate, sending a cloud of cement dust into the air. An automobile and a tractor-semitrailer, also southbound, then collided with the collapsed bridge spans. The cement-tank truckdriver sustained serious injuries; the drivers of the other two vehicles were killed.

Probable Cause: The cement truckdriver's failure to maintain his vehicle in the driving lane because of reduced alertness consistent with falling asleep. Contributing to the accident may have been the driver's use of marijuana. Contributing to the severity of the accident was the collapse of the bridge, after the semitrailer collided with and demolished the north column, that was a combined result of the nonredundant bridge design, the close proximity of the column bent to the road, and the lack of protection for the column bent from high-speed heavy-vehicle collision.

Recommendations: The Safety Board issued three recommendations to the following recipients: Federal Highway Administration (H-94-5 and -6) and American Association of State Highway Transportation Officials (H-94-7).

Collision of School Bus and Tractor-Semitrailer
Snyder, Oklahoma: 4 Killed, 7 Injured

About 3:28 p.m. on November 10, 1993, near Snyder, Oklahoma, a tractor-semitrailer operated by Cornell Construction Company was traveling southbound on U.S. Route 183 when it struck a small school bus that was crossing the highway while traveling west on County Line Road. The school busdriver said that she stopped at the stop sign and then proceeded to drive across Route 183. The truckdriver said the busdriver hesitated and then pulled out in front of his truck. The school bus was struck in the right side behind the right-front entrance door. Eight children were not wearing the available lap belts and were ejected. Four of the ejected children were killed. Injuries to the other four ranged from minor to serious. One child, the only occupant of the bus who was restrained, was not ejected and received minor injuries. The school busdriver was not ejected, but she was not wearing the lap/shoulder restraint and sustained severe injuries from contact with various parts of the bus interior. The truckdriver said he was wearing his lap belt and received minor injuries.

Probable Cause: The school busdriver did not see the approaching truck because her view was obstructed because she had not been provided with an effective strategy or other means for overcoming the view obstruction. Contributing to the severity of the accident was the truckdriver's failure to observe the speed advisory and the failure of Cornell Construction Company to systematically maintain the accident truck.

Recommendations: The Safety Board issued eight recommendations to the following recipients: National Highway Traffic Safety Administration (H-94-10- and 11), Federal Highway Administration (H-94-12), 50 States and District of Columbia (H-94-13 and -14), National Association of State Directors of Pupil Transportation Services (H-94-15 and -16), and Cornell Construction Company (H-94-17). The Safety Board reiterated one recommendation to 44 States (excluding Louisiana, New Jersey, New Mexico, Virginia, Washington, and West Virginia) and the District of Columbia (H-83-39).

Collision of Passenger Train and Large Transport Truck
Intercession, City, Florida: 59 Injured

About 12:40 p.m. on November 29, 1993, a 184-foot-long vehicle operated by Rountree Transport and Rigging was struck by an Amtrak passenger train while it was delivering an 82-ton turbine to the Kissimmee Utility Authority's Cane Island Project, an electricity-generating plant under construction near Intercession City, Florida. The private access road to the plant facility crosses over a single railroad track owned by CSX Transportation. Because of the configuration of the truck and the profile of the roadway, the cargo deck of the transporter began to bottom out on the roadway surface as the vehicle moved across the tracks and began down the descending grade. To gain sufficient clearance, the Rountree crew shimmed the transporter with the cargo deck on the tracks. As they finished raising the cargo deck and were preparing to move the vehicle, the lights and bells at the grade crossing activated. The gates descended, striking the turbine, and seconds later the Amtrak train struck the side of the cargo deck and the turbine. The locomotive and the first four cars of the eight-car train derailed, carrying the turbine and parts of the Rountree vehicle with them. Six people sustained serious injuries; 53 suffered minor injuries.

Probable Cause: The failure of Rountree Transport and Rigging to notify CSX in advance of its intent to cross the railroad track and to ensure through CSX that it was safe to do so. Contributing to the accident was deficiencies in the permitting process of CSX and the Florida Department of Transportation that resulted in a lack of appropriate guidance for permitting officials, oversize, low-clearance operators, and escort personnel.

Recommendations: The Safety Board issued 21 recommendations to the following recipients: American Association of State Highway and Transportation Officials (H-95-7), Specialized Carriers and Rigging Association (H-95-8 and -9), International Association of Chiefs of Police (H-95-10), National Sheriffs' Association (H-95-11), and National Committee on Uniform Traffic Laws and Ordinances (H-95-12); Association of American Railroads (R-95-24 and -25), American Short Line Railroad Association (R-95-26 and -27), Amtrak (R-95-28), Osceola County Emergency Management Division (R-95-29), and CSX Transportation (R-95-30 through -32); and American Gas Association (P-95-31), Interstate Natural Gas Association of America (P-95-32), American Public Gas Association (P-95-33), American Petroleum Institute (P-95-34), Central Florida Pipeline Corp. (P-95-35), and Florida Division of Emergency Management (P-95-36).

July 1994 Accident Report:

Truck Collision with Interstate Bridge
White Plains, New York: 1 Killed, 23 Injured

About 12:30 a.m. on July 27, 1994, a tractor cargo-tank semitrailer loaded with 9,200 gallons of propane (liquefied petroleum gas) and operated by Suburban Paraco Corp. was traveling east on I-287 in White Plains, New York. The truck drifted across the left lane onto the left shoulder and struck the guardrail. The tank hit a column of the Grant Avenue overpass. The tractor and semitrailer separated, and the front head of the tank fractured, releasing the propane, which vaporized into gas. The resulting vapor cloud expanded until it a found a source of ignition. When it ignited, according to an eyewitness, a fireball rose 200 or 300 feet in the air. The tank was propelled northward about 300 feet and landed on a frame house, engulfing it in flames. An area with a radius of about 400 feet was engulfed by fire. The truckdriver was killed; 23 people were injured.

Probable Cause: The reduction in the alertness of the driver (consistent with falling asleep) caused by his failure to properly schedule and obtain rest and the failure of Paraco Gas Corp. to exercise adequate oversight of its driver's hours of service. Contributing to the accident was the design of the highway geometrics and appurtenances, which did not accommodate an errant heavy vehicle. Contributing to the severity of the accident was the vulnerability of the bridge to collision from high-speed vehicles.

Recommendations: The Safety Board issued 12 recommendations to the following recipients: Federal Highway Administration (H-95-32 through -36), Research and Special Programs Administration (H-95-37), New York State Department of Transportation (H-95-38), American Association of State Highway and Transportation Officials (H-95-39), American Association of Motor Vehicle Administrators (H-95-40), American Trucking Associations (H-95-41), and Paraco Gas Corp. (H-95-42 and -43). The Board reiterated three recommendations to the Federal Highway Administration (H-94-5 and H-95-3 and -5).

January 1995 Safety Study:

Factors that Affect Fatigue in Heavy Truck Accidents

A January 1995 Safety Board safety study, based on 107 single-vehicle heavy truck accidents in which the drivers survived, came to 13 conclusions, including:

· The most critical factors in predicting fatigue-related accidents were the duration of the most recent sleep period, amount of sleep in the past 24 hours, and split sleep patterns.

· Truckdrivers in fatigue-related accidents had an average of 5.5 hours of sleep in the last sleep period before the accident, 2.5 hours less than drivers involved in nonfatigue-related accidents.

· Hours-of-service regulations did not provide the opportunity to obtain an adequate amount of sleep (at least 8 continuous hours) because they did not consider time needed for travel, eating, personal hygiene, recreation, or inability to fall asleep immediately at the beginning of the 8-hour off-duty period.

· Many drivers involved in fatigue-related accidents did not recognize that they were in need of sleep and believed that they were rested when they were not.

· About 67 percent of the drivers with schedule irregularities were involved in fatigue-related accidents and 38 percent of the drivers with regular schedules had fatigue-related accidents.

· Twenty-seven of the 107 drivers exceeded the hours-of-service limits at least once in the 96 hours preceding the accidents. About 82 percent of those had a fatigue-related accident.

Recommendations: The Safety Board issued six recommendations to the following recipients: Federal Highway Administration (H-95-1 through -5); Professional Truck Driver Institute of America and Commercial Vehicle Safety Alliance (H-95-5); American Trucking Associations and National Private Truck Council (H-95-5 and -6); National Industrial Transportation League, Independent Truck Owner Operators, Owner-Operator Independent Driver's Association, and International Brotherhood of Teamsters (H-95-6). The Board reiterated one recommendation to the Federal Highway Administration (H-90-28).

Collision Warning Technology - Multiple Vehicle Collision In Fog on Interstate
Menifee, Arkansas: 5 Killed, 1 Injured

About 1:50 a.m. on January 9, 1995, a multiple-vehicle rear-end collision occurred during fog at milepost 118 on I-40 near Menifee, Arkansas. The collision sequence initiated when an uninvolved vehicle and the accident lead vehicle entered dense fog. As the lead vehicle reportedly slowed from 65 to between 35 and 40 mph, it was struck in the rear. Subsequent collisions occurred as vehicles drove into the wreckage area at speeds varying from 15 to 60 mph. The accident eventually involved eight loaded truck-tractor semitrailer combinations and one light-duty delivery van. Eight vehicles were occupied by a driver only and one vehicle had a driver and codriver. Three truckdrivers, the codriver, and a van driver were killed; one truckdriver received a minor injury.

Probable Cause: Many of the drivers entered the area of dense fog at speeds that precluded successful evasive action to avoid the preceding or the stopped vehicles.

Recommendations: The Safety Board issued seven recommendations to the following recipients: Secretary of Transportation (H-95-44), National Highway Traffic Safety Administration (H-95-45), Federal Communications Commission (H-95-46), 50 States, District of Columbia, Puerto Rico, Virgin Islands, and U.S. Territories (H-95-47), Telecommunications Industry Association (H-95-48), Intelligent Transportation Society of America (H-95-49), and American Association of Motor Vehicle Administrators (H-95-50).

Highway-Railroad Grade Crossing Collision
Sycamore, South Carolina: 33 Injured

About 2:35 a.m. on May 2, 1995, Amtrak train 81, the Silver Star, on its southbound run from New York, New York, to Tampa, Florida, struck an O&J Gordon Trucking Company tractor-lowbed semitrailer combination that had been lodged for 30 to 35 minutes on a rural, high-profile vertical (humped) passive grade crossing about 1 mile north of Sycamore, South Carolina. At the time of the accident, the train was using a single track belonging to CSX Transportation. The 2 locomotive units and 14 of the 16 cars derailed, and the tractor and semitrailer were substantially damaged. Thirty-three people sustained minor injuries.

Probable Cause: The motor carrier's failure to provide to the driver appropriate guidance to respond to emergency situations. This led to the truckdriver's failure to both understand that the substandard profile of the Boogaloo Road grade crossing was incompatible with the truck he was operating and to notify the appropriate railroad and emergency personnel of the blocked crossing. Contributing to the accident was the absence of emergency notification information that the driver may have used to notify the railroad of the blocked crossing.

Recommendations: The Safety Board issued 12 recommendations to the following recipients: American Public Transit Association (R-96-1), American Short Line Railroad Association (R-96-2), Class 1 railroad and railroad systems (R-96-3), Secretary of Transportation (H-96-1 through -4), Federal Highway Administration (H-96-5), American Association of Motor Vehicle Administrators (H-96-6 and -7), American Trucking Associations (H-96-8), Operation Lifesaver (H-96-9 and -10), and O&J Gordon Trucking Company (H-96-11 and -12).

Managing Human Fatigue in Transportation: Promoting Safety and Productivity
Mclean, Virginia

On November 1 and 2, 1995, the Safety Board and National Aeronautics and Space Administration held a symposium in McLean, Virginia, focusing on the dangers of human fatigue in transportation, latest research of fatigue issues, and countermeasures to reduce fatigue-related accidents.

Highway issues: Some 126 highway participants discussed employee scheduling and fatigue countermeasures and education. The group suggested the following solutions: revise hour-of-service regulations, increase the number of driver rest areas, develop performance-based measures, develop better medical screening and adequate sleep standards, change company attitudes toward fatigue similar to the cultural change on drunk driving, provide specific training for drivers and management, and improve enforcement training for inspectors and police officers.

April 1996 Accident Report:

Truck Loss of Braking Control on Steep Downgrade and Vehicle Collision
Plymouth Meeting, Pennsylvania: 1 Killed, 1 Injured

On April 25, 1996, about 3:25 p.m., a 1988 Mack truck with a concrete mixer body was unable to stop as it approached a "T" intersection at the bottom of an exit ramp in Plymouth Meeting, Pennsylvania. As the truck proceeded through the intersection, it collided with and overrode a 1985 Subaru passenger car. The weather was clear and dry. The Subaru driver was found restrained in her vehicle and died; the truckdriver was unrestrained and sustained minor injuries.

Probable Cause: Improper maintenance of the accident truck by the JDM Materials Company, Inc., the fracture of the drain valve, and the inoperative low-air-warning switch that resulted in the driver's loss of braking control. Contributing to the accident was the lack of Federal and State inspection procedures for commercial vehicles with dual air brake systems that can detect either reversed air brake lines or inoperative low-air-warning switches.

Recommendations: The Safety Board issued nine recommendations to the following recipients: Federal Highway Administration (H-97-31), Commercial Vehicle Safety Alliance (H-97-32), American Trucking Associations (H-97-33), National Ready Mix Concrete Association (H-97-34), JDM Materials Company (H-97-35), Pennsylvania Department of Transportation (H-97-36), Truck Manufacturer's Association (H-97-37), National Highway Traffic Safety Administration (H-97-38), and Society of Automotive Engineers (H-97-39).

February 1997 Accident Report:

Multiple Vehicle Crossover on Four-Lane Highway
Slinger, Wisconsin: 8 Killed, 4 Injured

About 5:52 a.m. on February 17, 1997, a doubles truck with empty trailers, operated by Consolidated Freightways, was traveling northbound on U.S. 41 near Slinger, Wisconsin. The vehicle loss control and crossed a 50-foot depressed media into the southbound lanes. A flatbed truck loaded with lumber, operated by McFaul Transport, was traveling southbound on U.S. 41 and collided with the doubles truck, lost control, and crossed the media into the northbound lanes. A northbound passenger car with nine adult occupants struck and underrode the right front side of the flatbed truck. A refrigerator truck loaded with produce, operated by Glandt/Dahlke, was also traveling northbound and struck the right rear side of the flatbed truck. The road was clear after snowing the night before, but some motorists reported icy patches. Eight of the nine van occupants were killed, and the remaining occupant suffered serious injuries. Two of the truck drivers received minor injuries and were treated. The third driver refused treatment.

Probable Cause: The doubles truckdriver's lack of judgment in driving too fast for the configuration of his truck under the hazardous weather conditions. Contributing to the severity of the injuries and the reduced potentiality for survival was the lack of restraint use by the unrestrained occupants of the passenger van.

Recommendations: The Safety Board issued 19 recommendations to the following recipients: Federal Highway Administration (H-98-8 through -13); National Highway Traffic Safety Administration (H-98-14 through -17); National Association of Governors' Highway Safety representatives (H-98-18); American Trucking Associations, Motor Freight Carrier Association, and International Brotherhood of Teamsters (H-98-19 through -23); American Association of State Highway and Transportation Officials (H-98-24); Wisconsin Department of Transportation (H-98-25); and Independent Truckers and Drivers Association, National Private Truck Council, and Owner-Operators Independent Drivers Association (H-98-26). The Board reiterated one recommendation to the State of Wisconsin (H-97-2).

Corporate Culture and Transportation Safety
Arlington, Virginia

On April 24 and 25, 1997, the Safety Board held a symposium in Arlington, Virginia, to discuss the effect corporate management philosophies and practices have on transportation safety. Over the past few years, the Board has begun to address the role corporate culture plays in the cause of the accidents it investigates. The symposium featured experts from academia and industry, who discussed what works, what does not work, and what can be done to address this safety issue.

Highway Issues: The multimodal symposium attracted 56 highway participants who were asked to identify changes that would most improve the safety of the culture of their organizations. The group said it was necessary to develop a safety "counter culture" that would challenge the lack of personal responsibility for safety and the notion that there are "acceptable loses." Highway safety is an economic issue because of the high cost of accidents.

City Transit Bus Collision with Pedestrians
Normandy, Missouri: 4 Killed, 3 Injured

About 9:15 a.m. on June 11, 1997, a transit bus collided with seven pedestrians at a "park and ride" transit facility in Normandy, Missouri. The bus was being operated by a driver trainee who had just completed a routine stop at the station. After allowing the passengers to debark from the bus, the driver trainee began to move the bus forward to provide clearance for another bus to pass. The driver trainee, who was reportedly unable to stop the bus, allowed it to surmount the curb and continue onto the station platform. The resulting encroachment onto the platform resulted in the death of four pedestrians and the injury of three others.

Probable Cause: The driver trainee's misapplication of the accelerator, resulting in the bus's over ride of the curb and travel onto the occupied pedestrian platform. Contributing to the deaths and injuries was the absence of effective positive separation between the transit facility roadway and the station's pedestrian platform.

Recommendations: The Safety Board issued seven recommendations to the following recipients: Federal Highway Administration (H-98-1), Federal Transit Administration (H-98-2), American Association of State Highway and Transportation Officials (H-98-3), American Public Transit Association (H-98-4 and -5), and Community Transportation Association of America (H-98-6 and -7).

Collision of Tractor-Cargo Tank Semitrailer and Passenger Vehicle and Fire
Yonkers, New York: 1 Killed

At 12:10 a.m. on October 9,1997, a truck trailer pulling a cargo tank semitrailer was southbound on Central Park Avenue in Yonkers, New York. The truck, loaded with 8,800 gallons of gasoline, was going under an overpass of the New York State Thruway when it was struck by a southbound sedan. The car hit the tank truck in the area of its loading lines, releasing gasoline they contained. An ensuing fire destroyed both vehicles and the thruway overpass. The car driver was killed.

Probable Cause: The failure of the car driver to (1) stop for the red light or (2) reduce his speed or (3) apply his brakes soon enough to avoid the collision. Contributing to the severity of the accident was the fire resulting from the release of gasoline that the cargo tank's loading lines were carrying, as permitted by the U.S. Department of Transportation.

Recommendation: The Safety Board issued one recommendation to the Secretary of Transportation (H-98-27).

March 1998 Public Hearing:

Transit Bus System Safety
St. Louis, Missouri

On March 3 and 4, 1998, in St. Louis, Missouri, the Safety Board held a public hearing focusing on several issues, including Federal and State safety oversight of transit bus operations, adequacy of transit bus accident data to identify potential safety issues, and safety program guidelines for transit operators. The hearing stemmed from the June 1997 transit accident in Normandy, Missouri, that killed four and injured three.

Crashworthiness of Buses
Las Vegas, Nevada

On August 12, 1998, in Las Vegas, Nevada, the Safety Board held a public forum to explore what can be done to protect occupants in bus crashes, including bus standards and restraints used in other countries, types of possible restraints, and other types of injury reducing mechanisms. It also focused on the investigations into the following bus accidents: Flagstaff, Arizona, school bus high-speed rollover; Easton, Maryland, tractor-semitrailer/school bus collision; Monticello, Minnesota, tractor-semitrailer/school bus collision; Lancaster, Ohio, school bus/truck collision; Sinton, Texas, school bus/train collision; Buffalo, Montana, school bus/train collision; and Lenoir, Tennessee, truck/bus collision.

Transit Bus Safety Oversight

A November 1998 special investigation, based on four transit bus accidents in Missouri, Washington, New York, and Tennessee, came to four conclusions, including:

· Federal Transit Administration was unable to identify situations that may have lead to unsafe conditions on buses or to resolve unsafe conditions because of a lack of safety oversight and enforcement.

· U.S. Department of Transportation accident data did not accurately portray the transit bus industry's safety record because of data limitations to identify underlying causes or contributing factors to accidents, and lack of accurate and sufficient data within the transit bus industry prevents a thorough assessment of transit bus safety.

· A model comprehensive safety program was not available to all transit bus agencies.

Recommendations: The Safety Board issued seven recommendations to the following recipients: Department of Transportation (H-98-43 through -46), American Public Transit Association (H-98-47), Community Transportation Association of America (H-98-48), and American Association of State Highway and Transportation Officials (H-98-49).

February 1999 Special Investigation Report:

Selective Motorcoach Issues

A February 1999 special investigation was based on two accidents in 1995 and 1997 that are typical of the motorcoach accidents that the Safety Board has investigated over the years. On October 15, 1995, a motorcoach operated by Hammond Yellow Coach Line and occupied by a driver and 39 members of a high school booster club overturned when it entered an I-70 exit ramp in Indianapolis, Indiana. Two passengers were killed, 13 sustained serious injuries, and 26 received minor injuries. On July 29, 1997, a motorcoach, operated by Rite-Way Transportation and occupied by a driver and 34 members of a tour group, drifted off the side of I-95 near Stony Creek, Virginia, and down an embankment into the Nottoway River, where it came to rest on its left side. One passenger was killed, the driver and 3 passengers sustained serious injuries, and 28 passengers sustained minor injuries. The special investigation came to nine conclusions, including:

· The Rite-Way busdriver fell asleep and ran off the road. He became fatigued because the tour schedule imposed inverted duty-sleep periods and because additional well-rested drivers were not provided for relief.

· The Hammond busdriver's failing to respond appropriately cannot be determined; however several factors, including fatiguing conditions and the driver's unfamiliarity with the route, may have contributed to his failing to slow down for the exit ramp.

· Had the Office of Motor Carriers given Hammond an unsatisfactory rating based on the high percentage of vehicle defects, the brakes, speedometer, and air conditioner on the accident bus might have been repaired.

· During a passenger carrier compliance review, if a carrier does not meet the driver factor rating due to out-of-service vehicles and drivers, that determination should be serious enough to rate the carrier unsatisfactory overall.

· The strength and height needed to open an emergency window when a motorcoach is not upright poses a problem for some passengers, especially children, senior citizens, and some injury victims. Emergency instructions can be crucial to a safe and expedient evacuation in the event of an accident or emergency.

Recommendations: The Safety Board issued 15 recommendations to the following recipients: U.S. Department of Transportation (H-99-4 through -8), National Highway Traffic Safety Administration (H-99-9), American Bus Association (H-99-10 through -14), and United Motorcoach Association (H-99-15 through-18).

Transportation Recorders
Arlington, Virginia

The Safety Board and the International Transportation Safety Association will hold an international symposium in Arlington, Virginia, on May 3 through 5, 1999, focusing on recorder devices for trucks and buses and all modes of transportation. Topic areas include an overview of transportation recording capabilities (including regulatory requirements and industry standards); proactive use of recorded data for accident prevention and to improve operational efficiency; access to data issues such as privacy, proprietary, union contracts; and future recording requirements and capabilities.