Highway Accident Report


Adopted: July 17, 1990
COLLISION BETWEEN
CONSOLIDATED INDEPENDENT
SCHOOL DISTRICT SCHOOL BUS AND
VALLEY COCA-COLA BOTTLING COMPANY, INC.
TRACTOR-SEMITRAILER
INTERSECTION OF BRYAN AND TEXAS FARM-TO-MARKET ROAD 676
ALTON, TEXAS
SEPTEMBER 21, 1989

NTSB Number: HAR-90/02 NTIS Number: PB90-916201

SYNOPSIS

About 7:34 a.m ., central daylight time, on Thursday, September 21, 1989, a westbound school bus with 81 students operated by the Mission Consolidated Independent School District, Mission, Texas, and a northbound delivery truck operated by the Valley Coca-Cola Bottling Company, McAllen, Texas, collided at Bryan Road and Farm to Market Road Number 676 (FM 676) in Alton, Texas.

After the collision, the truck came to rest facing west on he right shoulder of FM 676. The school bus continued in a northwest direction and dropped approximately 24 feet into a caliche pit (excavation pit) partially filled with water, located in the northwest corner of the intersection. The bus came to rest on its left side facing southeast, totally submerged in approximately 10 feet of water, approximately 35 feet from the nearest 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.

Nineteen students died at the accident scene, and two died later in the hospital. The 21 fatalities were the result of drowning or complications related to the submersion. Furthermore, 3 students sustained serious injuries, 46 others sustained minor injuries, and 11 students were not injured.

The National Transportation Safety Board determines that the probable cause of the accident was 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.

The safety issues discussed in this report include:

Adequacy of school bus egress guidelines.

State and local emergency response planning for mass casualty accidents.

Adequacy of school busdriver medical examination report reviews.

Training of public safety personnel regarding calls for emergency assistance.

Vehicle maintenance procedures of Valley Coca-Cola Bottling Company.

Adequacy of Valley Coca-Cola Bottling Company driver training.

Crashworthiness of large school buses.

Safety recommendations addressing these issues were made to the National Highway Traffic Safety Administration; Texas Department of Public Safety; Texas Education Agency; Hidalgo County; City of Alton, Texas; Mission Consolidated Independent School District; Coca-Cola Enterprise, Inc.; Valley Coca-Cola Bottling Company, Inc.; and the National Association of State Directors of Pupil Transportation Services.

RECOMMENDATIONS

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

to the National Highway Traffic Safety Administration:

Revise Federal Motor Vehicle Safety Standard 217, Bus Window Retention and Release, to include a requirement that floor level emergency exits should be designed so that once opened they remain open during emergencies and school bus evacuations. (Class II, Priority Action) (H-90-74)

Revise Federal Motor Vehicle Safety Standard 208, Occupant Crash Protection, to include a requirement that lap shoulder belt systems for the driver position be installed in all newly manufactured buses, including city, intercity, small, and large. (Class II, Priority Action) (H-90-75)

Cooperate with the National Association of State Directors of Pupil Transportation Services to prepare a comprehensive school bus emergency evacuation - rescue guide. (Class II, Priority Action) (H-90-76)

Conduct research to determine the safety benefits and disadvantages of larger school bus side windows. (Class II, Priority Action) (H-90-77)

Revise Federal Motor Vehicle Safety Standard 217, Bus Window Retention and Release, to include a requirement for larger side windows in school buses if research proves that larger windows are more beneficial to school bus occupant safety. (Class II, Priority Action) (H-90-78)

--to the Texas Department of Public Safety

Examine the status of emergency management response plans statewide and work in coordination with and provide guidance to county and local governments in complying with the Department of Public Safety Division of Emergency Management emergency response plans requirements. (Class II, Priority Action) (H-90-79)

Evaluate in cooperation with Hidalgo County its compliance with the Texas Disaster Act of 1975. (Class II, Priority Action) (H-90-80)

--to the Texas Education Agency:

Coordinate the modification of school bus specifications prepared jointly with the State Purchasing and General Services Administration and the Texas Department of Public Safety, to include a requirement that lap shoulder belt systems for the driver position be installed in all newly manufactured buses including city, intercity, small, and large. (Class II, Priority Action) (H-90-81)

--to the Hidalgo County:

Develop a system to identify all traffic regulations and traffic control devices in the county and other appropriate jurisdictions within Hidalgo County. (Class II, Priority Action) (H-90-82)

Review emergency response plans in coordination with the Texas Department of Public Safety and update and enforce these plans to be in compliance with the Texas Disaster Act of 1975 and the Department of Public Safety Division of Emergency Management requirements. (Class II, Priority Action) (H-90-83)

--to the City of Alton:

Provide public safety personnel assigned to telephone duties with training in techniques of handling calls for emergency assistance. (Class II, Priority Action) (H-90-84)

Provide public safety personnel with guidance in handling emergency response, command, and on-scene control of community-wide emergencies and disaster. (Class II, Priority Action) (H-90-85)

--to the Mission Consolidated Independent School District:

Institute procedures that will ensure accurate review of the school busdriver medical examination report form and related documents and enforcement of any limitations. (Class II, Priority Action) (H-90-86)

--to the Coca-Cola Enterprises, Inc.:

Conduct a review and evaluate the number of mechanics and the provided resources in each of its operations to ensure that proper vehicle maintenance is performed in accordance with manufacturer specifications. (Class II, Priority Action) (H-90-87)

--to the Valley Coca-Cola Bottling Co., Inc.:

Develop and implement a formal truck driving training program including classroom and behind-the-wheel instruction with emphasis on driving articulated vehicles, using seatbelts, and complying with traffic regulations. The program should include maintaining adequate records and other documentation of driver examinations, including road test results. The training should be performed by qualified instructors). (Class II, Priority Action) (H-90-88)

Establish procedures and provide adequate resources to ensure that proper vehicle maintenance is performed in accordance with manufacturer specifications. (Class II, Priority Action) (H-90-89)

--to the National Association of State Directors of Pupil Transportation Services:

Cooperate with the National Highway Traffic Safety Administration to convene a national task force to prepare a comprehensive school bus emergency evacuation-rescue guide. (Class II, Priority Action) (H-90-90)

Also, the Safety Board reiterated Safety Recommendation H-89-5 to the National Highway Traffic Safety Administration:

Revise Federal Motor Vehicle Safety Standard 217, Bus Window Retention and Release, to require that school bus egress be based on vehicle occupant capacity and be no lower than those currently required for nonschool buses. (Class II, Priority Action) (H-89-5)

Jim Burnett, Member, filed the following concurring and dissenting statement:

I concur with the probable cause as adopted, but would have added that, "contributing to the severity of the accident was the deficient condition of the truck's brakes."

I voted not to adopt the report because the report deals inadequately with the issue of the performance of the brakes on the Coca Cola truck and its effect on the accident scenario.