Mexican Hat, Utah
January 6, 2008
NTSB Number: HAR-09-01
NTIS Number: PB2009-916201
Adopted April 21, 2009
On January 6, 2008, about 3:15 p.m. mountain standard time, a 2007 Motor Coach Industries 56-passenger motorcoach with a driver and 52 passengers on board departed Telluride, Colorado, en route to Phoenix, Arizona, as part of a 17-motorcoach charter. The motorcoach passengers were returning from a 3-day ski trip. The normal route from Telluride to Phoenix along Colorado State Route 145 was closed due to snow, and the lead driver planned an alternate route that included U.S. Route 163/191 through Utah.
About 8:02 p.m., the motorcoach was traveling southbound, descending a 5.6-percent grade leading to a curve to the left, 1,800 feet north of milepost 29 on U.S. Route 163. The weather was cloudy, and the roadway was dry at the time of the accident. After entering the curve, the motorcoach departed the right side of the roadway at a shallow angle, striking the guardrail with the right-rear wheel and lower coach body about 61 feet before the end of the guardrail. The motorcoach traveled approximately 350 feet along the foreslope (portion of roadside sloping away from the roadway), with the right tires off the roadway. The back tires lost traction as the foreslope transitioned into the drainage ditch.
The motorcoach rotated in a counterclockwise direction as it descended an embankment. The motorcoach overturned, struck several rocks in a drainage ditch bed at the bottom of the embankment, and came to rest on its wheels. During the 360-degree rollover sequence, the roof of the motorcoach separated from the body, and 50 of the 53 occupants were ejected. As a result of this accident, 9 passengers were fatally injured, and 43 passengers and the driver received injuries ranging from minor to serious.
The National Transportation Safety Board determines that the probable cause of this accident was the driver's diminished alertness due to inadequate sleep resulting from a combination of head congestion, problems acclimating to high altitude, and his sporadic use of his continuous positive airway pressure sleeping device during the accident trip. The driver's state of fatigue affected his awareness of his vehicle's excessive speed and lane position on a downhill mountain grade of a rural secondary road. Contributing to the accident's severity was the lack of an adequate motorcoach occupant protection system, primarily due to the National Highway Traffic Safety Administration's delay in developing and promulgating standards to enhance the protection of motorcoach passengers.
Major safety issues identified by this accident investigation include driver fatigue, excessive vehicle speed, hours-of-service violations, motor carrier trip planning, motorcoach occupant protection, and emergency medical notification and response with regard to large motorcoaches traveling on rural roads. As a result of its investigation, the Safety Board makes recommendations to the Federal Interagency Committee on Emergency Medical Services, the Utah Bureau of Emergency Medical Services, the Federal Highway Administration, the American Association of State Highway and Transportation Officials, the National Association of State Emergency Medical Services Officials, the American Bus Association, the United Motorcoach Association, and Arrow Stage Lines. The Safety Board also reiterates one previously issued recommendation to the Federal Motor Carrier Safety Administration.
As a result of its investigation of this accident, the National Transportation Safety Board makes the following safety recommendations:
To the Federal Interagency Committee on Emergency Medical Services:
Develop a plan that can be used by the States and public safety answering points to pursue funding for enhancements of wireless communications coverage that can facilitate prompt accident notification and emergency response along high-risk rural roads, as identified under SAFETEA-LU criteria, and along rural roads having substantial large bus traffic (as defined by the criteria established in Safety Recommendation H-09-7). (H-09-4)
Evaluate the system of emergency care response to large-scale transportation-related rural accidents and, once that evaluation is completed, develop guidelines for emergency medical service response and provide those guidelines to the States. (H-09-5)
To the Utah Bureau of Emergency Medical Services:
Establish written contingency plans for response to large-scale transportation-related emergencies along rural roads traveled by tour and charter buses, such as occurred in Mexican Hat, Utah, that cannot be handled by air medical services due to inclement weather. (H-09-6)
To the Federal Highway Administration:
Develop and implement, in conjunction with the American Association of State Highway and Transportation Officials and the National Association of State Emergency Medical Services Officials, criteria based on traffic patterns, passenger volume, and bus types that can be used to assess the risks of rural travel by large buses. Use this criteria as part of the SAFETEA-LU requirement to identify and select Highway Safety Improvement Program projects. (H-09-7)
To the American Association of State Highway and Transportation Officials and the National Association of State Emergency Medical Services Officials:
Work with the Federal Highway Administration to develop and implement criteria based on traffic patterns, passenger volume, and bus types that can be used to assess the risks of rural travel by large buses. (H-09-8)
To the American Bus Association and the United Motorcoach Association:
Inform your members through Web sites, newsletters, and conferences of the circumstances of the Mexican Hat, Utah, accident. The prepared information should encourage charter operators to develop written contingency plans for each charter to ensure that trip planning is in place in the event of driver fatigue, incapacitation, or illness or in the event of trip delays necessitating replacement drivers to avoid hours-of-service violations and inform drivers of their trip's contingency plans. The prepared information should also provide information about the risks of operating in rural areas without wireless telephone coverage and advise members to carry mobile cellular amplifiers or satellite-based devices to communicate emergency events. (H-09-9)
To Arrow Stage Lines:
Develop written contingency plans for each charter to ensure that trip planning is in place in the event of driver fatigue, incapacitation, or illness or in the event of trip delays necessitating replacement drivers to avoid hours-of-service violations and inform drivers of their trip's contingency plans. (H-09-10)
The National Transportation Safety Board reiterates the following recommendation:
To the Federal Motor Carrier Safety Administration:
Require all interstate commercial vehicle carriers to use electronic on-board recorders that collect and maintain data concerning driver hours of service in a valid, accurate, and secure manner under all circumstances, including accident conditions, to enable the carriers and their regulators to monitor and assess hours-of-service compliance. (H-07-41)
The following recommendations to the National Highway Traffic Safety Administration are classified "Open—Unacceptable Response":
In 2 years, develop performance standards for motorcoach occupant protection systems that account for frontal impact collisions, side impact collisions, rear impact collisions, and rollovers. (H-99-47)
Once pertinent standards have been developed for motorcoach occupant protection systems, require newly manufactured motorcoaches to have an occupant crash protection system that meets the newly developed performance standards and retains passengers, including those in child safety restraint systems, within the seating compartment throughout the accident sequence for all accident scenarios. (H-99-48)
In 2 years, develop performance standards for motorcoach roof strength that provide maximum survival space for all seating positions and that take into account current typical motorcoach window dimensions. (H-99-50)
Once performance standards have been developed for motorcoach roof strength, require newly manufactured motorcoaches to meet those standards. (H-99-51)