Highway Accident Report - Collision Between a Ford Dump Truck and Four Passenger Cars

Glen Rock, Pennsylvania
April 11, 2003

NTSB Number: HAR-06-01
NTIS Number: PB2006-916201
February 07, 2006
PDF

Executive Summary

About 3:36 p.m., eastern daylight time, on April 11, 2003, in the Borough of Glen Rock, Pennsylvania, a 1995 Ford dump truck owned and operated by Blossom Valley Farms, Inc., was traveling southbound on Church Street, a two-lane, two-way residential street with a steep downgrade, when the driver found that he was unable to stop the truck. The truck struck four passenger cars, which were stopped at the intersection of Church and Main Streets, and pushed them into the intersection. One of the vehicles struck three pedestrians (a 9-year-old boy, a 7-year-old boy, and a 7-year-old girl), who were on the sidewalk on the west side of Church Street. The truck continued across the intersection, through a gas station parking lot, and over a set of railroad tracks before coming to rest about 300 feet south of the intersection. As a result of the collision, the driver and an 11- year-old occupant of one of the passenger cars received fatal injuries, and the three pedestrians who were struck received minor-to-serious injuries. The six remaining passenger car occupants and the truck driver were not injured.

The National Transportation Safety Board determines that the probable cause of this accident was the lack of oversight by Blossom Valley Farms, Inc., which resulted in an untrained driver improperly operating an overloaded, air brake-equipped vehicle with inadequately maintained brakes. Contributing to the accident was the misdiagnosis of the truck's underlying brake problems by mechanics involved with the truck's maintenance; also contributing was a lack of readily available and accurate information about automatic slack adjusters and inadequate warnings about the safety problems caused by manually adjusting them.

During the investigation, the Safety Board identified the following major safety issues:

  • Maintaining air brakes equipped with automatic slack adjusters,
  • Knowledge and skills needed to drive air brake-equipped vehicles, and
  • Motor carrier oversight.

As a result of this accident investigation, the Safety Board makes recommendations to the Federal Motor Carrier Safety Administration, the 50 States and the District of Columbia, the Commercial Vehicle Safety Alliance, manufacturers and marketers of automatic slack adjusters, manufacturers of vehicles equipped with air brakes, the National Institute for Automotive Service Excellence (ASE), and publishers of ASE certification test study guides.

Recommendations

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

To the Federal Motor Carrier Safety Administration:

Work with the Commercial Vehicle Safety Alliance to develop and add to the North American Standard Inspection training materials a module that emphasizes that manually adjusting automatic slack adjusters is dangerous and should not be done, except during installation or in an emergency to move the vehicle to a repair facility, because manual adjustment of this brake component (1) fails to address the true reason why the brakes are not maintaining adjustment, giving the operator a false sense of security about the effectiveness of the brakes, which are likely to go out of adjustment again soon, and (2) causes abnormal wear to the internal adjusting mechanism for most automatic slack adjusters, which may lead to failure of this brake component. (H-06-1)

Require drivers of commercial vehicles that weigh less than 26,000 pounds and are equipped with air brakes to undergo training and testing to demonstrate proficiency in the inspection and operation of air-braked vehicles; the training should emphasize that manually adjusting automatic slack adjusters is dangerous and should not be done, except during installation or in an emergency to move the vehicle to a repair facility. (H-06-2)

To the District of Columbia and the 50 States:

When you incorporate the information on automatic slack adjusters from the new American Association of Motor Vehicle Administrators model Commercial Driver License Manual into your Commercial Driver's License manual, include a statement that the manual adjustment of automatic slack adjusters is dangerous because it gives the vehicle operator a false sense of security about the effectiveness of the braking system. (H-06-3)

Adopt an air brake endorsement for drivers' licenses that would require training and testing of drivers who drive air brake-equipped vehicles to ensure their proficiency in the operation of air-braked vehicles; the training should emphasize that manually adjusting automatic slack adjusters is dangerous and should not be done, except during installation or in an emergency to move the vehicle to a repair facility. (H-06-4)

To the District of Columbia and the 24 States (Alabama, Arkansas, California, Connecticut, Hawaii, Illinois, Louisiana, Maine, Maryland, Michigan, Minnesota, New Hampshire, New Jersey, New York, Ohio, Oklahoma, Pennsylvania, Rhode Island, Texas, Utah, Vermont, Virginia, West Virginia, and Wisconsin) that have commercial vehicle inspection programs:

Include in your truck inspector training courses a module on automatic slack adjusters that emphasizes that manually adjusting automatic slack adjusters is dangerous and should not be done, except during installation or in an emergency to move the vehicle to a repair facility, because manual adjustment of this brake component (1) fails to address the true reason why the brakes are not maintaining adjustment, giving the operator a false sense of security about the effectiveness of the brakes, which are likely to go out of adjustment again soon, and (2) causes abnormal wear to the internal adjusting mechanism for most automatic slack adjusters, which may lead to failure of this brake component. (H-06-5)

To the Commercial Vehicle Safety Alliance:

Revise your pamphlet, Air Brake Adjustment—Why is it so important?, to emphasize that the manual adjustment of automatic slack adjusters is a dangerous practice that can have serious consequences, because it gives the operator a false sense of security about the effectiveness of the brakes, which are likely to go out of adjustment again soon. (H-06-6)

Work with the Federal Motor Carrier Safety Administration to develop and add to the North American Standard Inspection training materials a module that emphasizes that manually adjusting automatic slack adjusters is dangerous and should not be done, except during installation or in an emergency to move the vehicle to a repair facility, because manual adjustment of this brake component (1) fails to address the true reason why the brakes are not maintaining adjustment, giving the operator a false sense of security about the effectiveness of the brakes, which are likely to go out of adjustment again soon, and (2) causes abnormal wear to the internal adjusting mechanism for most automatic slack adjusters, which may lead to failure of this brake component. (H-06-7)

To Haldex Brake Products Corporation, Bendix Commercial Vehicle Systems LLC, Bendix Spicer Foundation Brake LLC, Gunite Corporation, ArvinMeritor, Inc., and Crewson Industries, Inc. (manufacturers and marketers of automatic slack adjusters):

Revise your product literature to include conspicuously placed wording that clearly states that automatic slack adjusters should not be manually adjusted in an effort to correct excessive pushrod stroke, because this condition indicates that a problem exists with the automatic adjuster, with the installation of the adjuster, or with related foundation brake components, which manual adjustment will not fix. Further, the literature dangerous practice that could have serious consequences, because it gives the operator a false sense of security about the effectiveness of the brakes, which are likely to go out of adjustment again soon. (H-06-8)

To Freightliner LLC, Mack Trucks, Inc., International Truck and Engine Corporation, Kenworth Truck Company, Peterbilt Motors Company, Volvo Trucks North America, Inc., Ford Motor Company, General Motors Corporation, Hino Motor Sales U.S.A., Inc., and Nissan Diesel America Incorporated (manufacturers of vehicles equipped with air brakes):

Revise your product manuals to include conspicuously placed wording that clearly states that automatic slack adjusters should not be manually adjusted in an effort to correct excessive pushrod stroke, because this condition indicates that a problem exists with the automatic adjuster, with the installation of the adjuster, or with related foundation brake components, which manual adjustment will not fix. Further, the product manuals should state that manual adjustment of automatic slack adjusters is a dangerous practice that could have serious consequences, because it gives the operator a false sense of security about the effectiveness of the brakes, which are likely to go out of adjustment again soon. (H-06-9)

To the National Institute for Automotive Service Excellence:

Include the following information in your T4 brake certification testing materials: manually adjusting automatic slack adjusters is dangerous and should not be done, except during installation or in an emergency to move the vehicle to a repair facility, because manual adjustment of this brake component (1) fails to address the true reason why the brakes are not maintaining adjustment, giving the operator a false sense of security about the effectiveness of the brakes, which are likely to go out of adjustment again soon, and (2) causes abnormal wear to the internal adjusting mechanism for most automatic slack adjusters, which may lead to failure of this brake component. (H-06-10)

To Motor Age, Mitchell 1, and Thompson Delmar Learning (publishers of National Institute for Automotive Service Excellence certification test study guides):

Include the following information in your National Institute for Automotive Service Excellence study guides: manually adjusting automatic slack adjusters is dangerous and should not be done, except during installation or in an emergency to move the vehicle to a repair facility, because manual adjustment of this brake component (1) fails to address the true reason why the brakes are not maintaining adjustment, giving the operator a false sense of security about the effectiveness of the brakes, which are likely to go out of adjustment again soon, and (2) causes abnormal wear to the internal adjusting mechanism for most automatic slack adjusters, which may lead to failure of this brake component. (H-06-11)