Highway Accident Report

Motorcoach Rollover on U.S. Highway 59

Near Victoria, Texas
January 2, 2008

NTSB Number: HAR-09-03-SUM
NTIS Number: PB2009-916203
Adopted: December 8, 2009
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Executive Summary:

On January 2, 2008, about 4:13 a.m., a 2005 Volvo 47-passenger motorcoach, operated by a 42-year-old driver and carrying 47 passengers, was proceeding northbound on U.S. Highway 59 (U.S. 59) about 5 miles south of Victoria, Texas, when the motorcoach driver partially drifted off the right edge of the roadway. The driver oversteered to the left to avoid leaving the roadway, resulting in the motorcoach coming back across both lanes, departing the left edge of the roadway, and partially entering an earthen median. The driver oversteered again to the right in an attempt to reenter the roadway and then oversteered to the left a second time upon realizing the motorcoach had gone too far right. As a result of the final oversteer, the motorcoach yawed to the left, rotated counterclockwise, and overturned onto its right side. The motorcoach's right rear struck a guardrail as the motorcoach slid on its right side approximately 112 feet before coming to rest across the roadway. Within 5 minutes, and before emergency responders arrived on scene, a 2001 Ford Ranger pickup truck also traveling northbound on U.S. 59 struck the underside of the motorcoach forward of the rear axle. As a result of the initial motorcoach rollover, 1 passenger was fatally injured, and 46 passengers and the driver received injuries ranging from minor to serious. The driver of the pickup truck sustained minor injuries when the pickup truck struck the undercarriage of the motorcoach.

Probable Cause

The National Transportation Safety Board determines that the probable cause of this accident was the driver's falling asleep, which caused him to partially drift off the road, resulting in oversteer corrections when the driver regained awareness, and subsequent vehicle loss of control and overturn. Contributing to the severity of the unrestrained passengers' injuries was their striking objects and other passengers inside the motorcoach, as well as the partial ejections that occurred when the motorcoach overturned during the accident.

The investigation identified safety issues that the NTSB has not previously addressed: the lack of FMCSA oversight of passenger motor carrier leasing agreements and the registration and use of non-Federal Motor Vehicle Safety Standard-compliant, passenger-carrying vehicles in commercial motor carrier operations in the United States. The report also addresses continuing deficiencies in motor carrier operating authority issues, safety rating methodology, and the New Entrant Safety Assurance Program. This summary report examines the Victoria accident and its proximate cause and then proceeds to explore, in depth, specific safety issues that were not being adequately addressed by Federal and state oversight authorities due to loopholes in safety processes. As a result of its investigation, the NTSB has made recommendations to the U.S. Department of Transportation, the National Highway Traffic Safety Administration, the Federal Motor Carrier Safety Administration, the U.S. Customs and Border Protection Agency, the American Association of Motor Vehicle Administrators, the International Registration Plan, Inc., and the Commercial Vehicle Safety Alliance. The NTSB also reiterated two previously issued recommendations to the Federal Motor Carrier Safety Administration.

Recommendations

New Recommendations

As a result of its investigation, the National Transportation Safety Board makes the following safety recommendations:

To the Department of Transportation:

Direct the National Highway Traffic Safety Administration and the Federal Motor Carrier Safety Administration to work in conjunction with the U.S. Customs and Border Protection Agency to develop and implement a process to detect motor carriers that are currently operating non-FMVSS-compliant motorcoaches or other passenger-carrying commercial motor vehicles, other than exempted vehicles, in the United States (outside of the commercial zone), and when such vehicles are detected, to ensure that the Federal Motor Carrier Safety Administration has the authority to place such vehicles out of service and require that these motor carriers cease operating those vehicles in commercial interstate passenger service or face revocation of their operating authority. (H-09-29)

To the National Highway Traffic Safety Administration:

Develop, in conjunction with the Federal Motor Carrier Safety Administration, a Web-based database of FMVSS-compliant passenger-carrying commercial motor vehicles that can be utilized by Federal, state, and local enforcement inspection personnel to identify non-FMVSS-compliant passenger-carrying commercial motor vehicles so that these vehicles (other than exempted vehicles) are placed out of service and cease operating in the United States. Implement a process to periodically update this database. (H-09-30)

When the database requested in Safety Recommendation H-09-30 is completed, make the database known and accessible to state vehicle registration agencies and to Federal, state, and local enforcement inspection personnel for their use during roadside inspections and compliance reviews to identify non-FMVSS-compliant passenger-carrying commercial motor vehicles. (H-09-31)

To the Federal Motor Carrier Safety Administration:

Update and redistribute your "Driver Fatigue Video" to include current information on fatigue and fatigue countermeasures and make the video available electronically. Implement a plan to regularly update and redistribute the video. (H-09-32)

Revise 49 Code of Federal Regulations Part 376 to require that passenger motor carriers are subject to the same limitations on the leasing of equipment as interstate for-hire motor carriers of cargo. (H-09-33)

Seek statutory authority to deny or revoke operating authority for commercial interstate motor carriers found to have applications for operating authority in which the applicant failed to disclose any prior operating relationship with another motor carrier, operating as another motor carrier, or being previously assigned a U.S. Department of Transportation number. (H-09-34)

Apply the evasion detection algorithm process against all interstate passenger carriers that obtained Federal Motor Carrier Safety Administration operating authority, after the New Entrant Safety Assurance Program began in 2003 but before the program began vetting those carriers, to verify that those new entrant carriers do not have a concealed history of poor safety management controls because they were able to reenter interstate commerce undetected as reincarnated carriers. (H-09-35)

Establish a requirement to review all passenger carrier lease agreements during new entrant safety audits and compliance reviews to identify and take action against carriers that have lease agreements that result in a loss of operational control by the certificate holder. (H-09-36)

Assist the National Highway Traffic Safety Administration in developing a Web-based database of FMVSS-compliant passenger-carrying commercial motor vehicles that can be utilized by Federal, state, and local enforcement inspection personnel to identify non-FMVSS-compliant passenger-carrying commercial motor vehicles so that these vehicles (other than exempted vehicles) are placed out of service and cease operating in the United States. Implement a process to periodically update this database. (H-09-37)

Require that Federal and state inspectors utilize the database requested in Safety Recommendation H-09-37 during both roadside and compliance review inspections of passenger-carrying commercial motor vehicles to identify and place out of service non-FMVSS-compliant vehicles. (H-09-38)

Institute a requirement for Federal and state enforcement officials to obtain training on a procedure to physically inspect passenger-carrying commercial motor vehicles for an FMVSS compliance label, and work with the Commercial Vehicle Safety Alliance to develop and provide this training. (H-09-39)

Require that passenger motor carriers certify on their OP-1(P) forms (Application for Motor Passenger Carrier Authority) and initial MCS-150 form (Motor Carrier Identification Report [Application for USDOT Number]) and subsequent required biennial submissions that all vehicles operated, owned, or leased per trip or per term met the FMVSSs in effect at the time of manufacture. (H-09-40)

Seek statutory authority to suspend, revoke, or withdraw a motor carrier's operating authority upon discovering the carrier is operating any non-FMVSS-compliant passenger-carrying commercial motor vehicles, a violation of the FMVSS-compliant certification requested in Safety Recommendation H-09-40. (H-09-41)

To the U.S. Customs and Border Protection Agency:

Assist the U.S. Department of Transportation in developing a process to detect and report to the Department of Transportation information on motor carriers identified during your border crossing inspections of passenger-carrying commercial motor vehicles to be currently operating non-FMVSS-compliant passenger-carrying commercial motor vehicles, other than exempted vehicles, in the United States (outside of the commercial zone), and assist the Department in ensuring such vehicles are placed out of service and requiring these motor carriers cease operating those vehicles in commercial interstate passenger service. (H-09-42)

Incorporate the definition of interstate commerce from 49 Code of Federal Regulations 390.5 into 19 Code of Federal Regulations 12.80 in order to provide a uniform, coherent definition for what constitutes an imported vehicle. (H-09-43)

To the American Association of Motor Vehicle Administrators:

Assist the International Registration Plan, Inc., in developing and distributing to the states and the District of Columbia a model policy for verifying that newly registered passenger-carrying commercial motor vehicles are certified as having complied with the appropriate FMVSSs in effect at the time of manufacture, as referenced in Title 49 Code of Federal Regulations Part 567. (H-09-44)

To International Registration Plan, Inc.:

In conjunction with the American Association of Motor Vehicle Administrators, develop and distribute to the states and the District of Columbia, a model policy, within the International Registration Plan registration process, for verifying that newly registered passenger-carrying commercial motor vehicles are certified as having complied with the appropriate FMVSSs in effect at the time of manufacture, as referenced in Title 49 Code of Federal Regulations Part 567. (H-09-45)

Commercial Vehicle Safety Alliance:

Revise the North American Standard Out-of-Service Criteria to include passenger motor carriers discovered to be violating their operating authority by operating non-FMVSS-compliant passenger-carrying commercial motor vehicles. (H-09-46)

Work with the Federal Motor Carrier Safety Administration to develop and provide training on a procedure for Federal and state enforcement officials to physically inspect passenger-carrying commercial motor vehicles for an FMVSS compliance label. (H-09-47)

Previously Issued Recommendation Reiterated in This Report

As a result of its investigation, the National Transportation Safety Board reiterates the following safety recommendation:

To the Federal Motor Carrier Safety Administration:

To protect the traveling public until completion of the Comprehensive Safety Analysis 2010 Initiative, immediately issue an Interim Rule to include all Federal Motor Carrier Safety Regulations in the current compliance review process so that all violations of regulations are reflected in the calculation of a carrier's final rating. (H-07-3)

Previously Issued Recommendation Reiterated and Reclassified in This Report

As a result of its investigation, the National Transportation Safety Board reiterates and reclassifies Safety Recommendation H-99-6. This recommendation, previously classified "Open-Acceptable Response," is reclassified "Open-Unacceptable Response."

To the Federal Motor Carrier Safety Administration:

Change the safety fitness rating methodology so that adverse vehicle or driver performance-based data alone are sufficient to result in an overall unsatisfactory rating for a carrier. (H-99-6)