Motorcoach Run-Off-the-Road and Collision With Vertical Highway Signpost Interstate 95 Southbound

New York City, New York
March 12, 2011

NTSB Number: HAR-12-01
NTIS Number: PB2012-916201
Adopted: June 5, 2012
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Executive Summary

On March 12, 2011, about 5:38 a.m., a 1999 Prevost 56-passenger motorcoach, operated by World Wide Travel of Greater New York, headquartered in Brooklyn, was traveling southbound on Interstate 95, en route from the Mohegan Sun Casino in Uncasville, Connecticut, to New York City, and carrying 32 passengers. While in the vicinity of mile marker 3.2, the motorcoach departed from the travel lanes to the right, driving over the rumble strips on the right shoulder edge. The motorcoach then crossed over the 10-foot-wide paved shoulder and struck a strong-post W-beam guardrail, traveling about 480 feet alongside and on the guardrail, before finally overturning 90° onto its right side and flattening the guardrail. The front of the vehicle subsequently collided with a vertical highway signpost consisting of two vertical 8-inch-diameter steel tubular poles linked by cross-beam diagonal metal supports. The front roof also collided with a steel electrical box mounted to the sign support structure. After the motorcoach struck the support structure and electrical box, the two poles entered the passenger compartment along the base of the passenger windows as the vehicle slid forward. The impact resulted in the roof panel being torn from the bus body for almost the entire length of the bus. As a result of this accident, 15 passengers were killed, 17 passengers received serious-to-minor injuries, and the bus driver received minor injuries.

Investigative Synopsis

The accident occurred when the motorcoach departed from the travel lanes to the right at about a 7° departure angle from the roadway; no tire marks were made on the travel lanes to indicate braking or evasive steering. The driver then traversed a 10-foot-wide paved shoulder enhanced with rumble strips and struck a roadside barrier. Postaccident examination of electronic control module data revealed that the accident motorcoach was traveling at least 64 mph for at least 10 seconds before it struck the guardrail. The control module data also indicated that the driver did not apply the brakes in the 60 seconds before leaving the travel lanes, crossing the shoulder, and striking the guardrail.

Safety issues identified in this accident investigation include:

  • Motorcoach driver fatigue and onboard monitoring systems: The motorcoach driver was experiencing both acute sleep loss and cumulative sleep debt at the time of the accident. Because of the driver's activities in the days leading to the accident, his sleep opportunities did not exceed 4 hours. Circadian factors related to the driver's inverted work schedule and the time of day at which the accident occurred, about 5:38 a.m., would have exacerbated the effects of fatigue. No Federal requirements currently exist for motor carriers to implement fatigue management programs. Research into fatigue management technologies is ongoing, though safety systems that monitor driver behavior, such as providing warnings to drowsy drivers or detecting unsafe driving behaviors, are already in the marketplace. However, motor carriers are in need of additional guidance on how to effectively use in-vehicle technology to monitor and improve driver safety.
  • Commercial driver license history: A driver's history of crashes or moving violations is directly related to future crash risk. Currently, a motorcoach driver-applicant must submit a 10-year commercial driving employment history, and the states must provide carriers hiring commercial drivers with a 3-year driving history. However, for preemployment screening, motor carriers need access to a longer history of a commercial driver's license record to make informed hiring decisions. The National Transportation Safety Board (NTSB) is currently investigating two other accidents involving high-risk drivers.
  • Heavy vehicle1 speed limiters: The speed limit at the accident location was 50 mph, yet the motorcoach driver was traveling 64 mph after departing the travel lanes of I-95. Had he been driving at or below the speed limit (50 mph), he may have been able to steer the bus away from the guardrail, preventing the rollover and collision with the vertical highway signpost. The motorcoach was equipped with a speed limiter, but it was set to 78 mph. Although there is significant interest in the use of advanced speed limiting technology, no Federal performance standards address such technology or require its installation in heavy vehicles.
  • Safety management systems and motor carrier safety ratings: The practices of both motor carriers that had employed the accident driver-such as not adhering to hours-of-service requirements and improperly addressing speeding violations-indicate inadequate oversight of drivers, which impacts passenger safety. This accident is one of many investigated by the NTSB in which the motor carrier's safety processes, as well as its corporate culture, may have set the stage for the driver's on-road operating performance. Motor carriers should receive a determination of their fitness to operate and a safety rating based upon on-road performance and adherence to safety regulations, performance that is currently tracked by the Federal Motor Carrier Safety Administration's Safety Measurement System. Federal rulemaking on a new safety fitness determination process is scheduled to begin by early 2013. The performance rating will be based on all safety-based regulations, rather than on critical and acute violations only. It will replace the current safety rating process, which relies exclusively on onsite investigation or compliance review. In addition, as part of a process called a Safety Management Cycle, motor carriers should be educated about, and required to actively assess, the root cause of safety violations that are correlated to crash risk.
  • Roadside barriers for heavy commercial passenger vehicles: The NTSB evaluated roadside conditions at the accident site to determine the guardrail characteristics necessary to shield the vertical highway signpost. Examination of available research and testing methods for barriers reveals that guidance given to the states on upgrading barrier systems is inadequate. In addition, there is a clear need nationwide for higher performance traffic barriers to redirect heavy commercial vehicles and motorcoaches. New barrier performance standards are needed along with, possibly, new barrier designs with height and deflection characteristics capable of safely redirecting heavy commercial passenger vehicles from point hazards.
  • Occupant injuries and motorcoach crashworthiness: The accident motorcoach hit the guardrail, rolled over, and slid on its passenger side into the vertical highway signpost. The point of impact on the motorcoach, just below the roofline, was not capable of attenuating a frontal crash and the resulting impact loading was beyond the vehicle's design scope. Further, survival space was compromised for passengers in the path of the vertical signpost structure. Because motorcoaches are not currently required to meet Federal performance standards for occupant protection, the 1999 Prevost motorcoach was not equipped with passenger seat restraint systems-systems which, if installed, could reduce ejection and secondary impact injuries. As a result of this accident investigation, the NTSB identified the design of seat spacing and armrests as a means of reducing occupant injury and advocates for their evaluation and, if safe configurations and spacing are identified, the development of guidelines.

Probable Cause

The National Transportation Safety Board determines that the probable cause of the accident was the motorcoach driver's failure to control the motorcoach due to fatigue resulting from failure to obtain adequate sleep, poor sleep quality, and the time of day at which the accident occurred. Contributing to the accident was inadequate safety oversight of the accident driver by World Wide Travel's management. Contributing to the severity of the accident was the motorcoach's speed and a guardrail that was not designed to redirect the heavy vehicle and did not prevent it from colliding with the vertical highway signpost. Contributing to the severity of passenger injuries was the extensive intrusion of the vertical highway signpost into the passenger compartment.

As a result of this accident investigation, the National Transportation Safety Board makes recommendations to the Federal Motor Carrier Safety Administration, the National Highway Traffic Safety Administration, the Federal Highway Administration, the American Association of State Highway and Transportation Officials, the American Bus Association, the National Motorcoach Network, and the United Motorcoach Association. The National Transportation Safety Board reiterates four recommendations to the Federal Motor Carrier Safety Administration and two recommendations to the National Highway Traffic Safety Administration.

Recommendations

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

New Recommendations

To the Federal Motor Carrier Safety Administration:

Develop and disseminate guidance for motor carriers on how to most effectively use currently available onboard monitoring systems and develop a plan to periodically update the guidance. (H-12-13)

Upon completion of the field operational tests for onboard monitoring systems, determine whether test results indicate that such systems would reduce accidents or injuries, and, if so, require commercial motor carriers to use these systems to improve driver safety. (H-12-14)

Revise 49 Code of Federal Regulations 391.23 to require that motor carriers obtain a 10-year driving history for all prospective commercial vehicle drivers. (H-12-15)

Revise 49 Code of Federal Regulations 384.225 to require that states retain on the Commercial Driver's License Information System driver record all convictions, disqualifications, and other licensing actions for violations during the prior 10 years. (H-12-16)

Include safety measurement system rating scores in the methodology used to determine a carrier's fitness to operate in the safety fitness rating rulemaking for the new Compliance, Safety, Accountability initiative. (H-12-17)

Include in the safety fitness rating rulemaking for the new Compliance, Safety, Accountability initiative a structured process, such as the Safety Management Cycle, to be used by Federal Motor Carrier Safety Administration investigators and their state Motor Carrier Safety Assistance Program agents, as an audit tool for investigators to (1) identify the root cause of safety risks found during compliance reviews, and (2) deliver constructive guidance to motor carriers to ensure the promotion of safety management. (H-12-18)

Include information regarding the Safety Management Cycle in your Safety is Good Business motor carrier website. (H-12-19)

To the National Highway Traffic Safety Administration:

Develop performance standards for advanced speed-limiting technology, such as variable speed limiters and intelligent speed adaptation devices, for heavy vehicles, including trucks, buses, and motorcoaches. (H-12-20)

After establishing performance standards for advanced speed-limiting technology for heavy commercial vehicles, require that all newly manufactured heavy vehicles be equipped with such devices. (H-12-21)

Evaluate the effects of seat spacing and armrests as factors for potential occupant injury, and if safer spacing or armrest configurations are identified, develop and implement appropriate guidelines. (H-12-22)

To the Federal Highway Administration:

Work with the American Association of State Highway and Transportation Officials to establish performance and selection guidelines for state transportation agencies to use in developing objective warrants for high-performance barriers applicable to new construction and rehabilitation projects where barrier replacement has been determined to be appropriate. (H-12-23)

Until barrier testing has been completed, selection guidelines have been developed, and barrier guidance has been updated in the American Association of State Highway and Transportation Officials Roadside Design Guide, provide information to state transportation agencies about (1) the unique considerations associated with commercial passenger vehicle "run-off-the-road" accidents involving point hazards, and (2) the associated potential for catastrophic loss of life. (H-12-24)

To the American Association of State Highway and Transportation Officials:

Work with the Federal Highway Administration to establish performance and selection guidelines for state transportation agencies to use in developing objective warrants for high-performance barriers applicable to new construction and rehabilitation projects where barrier replacement has been determined to be appropriate. (H-12-25)

Evaluate the adequacy of barrier systems currently approved through National Cooperative Highway Research Program Report 350 or the Manual for Assessing Safety Hardware for safely redirecting commercial passenger vehicles and, if warranted, develop new barrier designs incorporating appropriate height and deflection characteristics capable of safely redirecting commercial passenger vehicles. (H-12-26)

Once barrier testing has been completed and selection guidelines have been developed, revise chapter 5 of the Roadside Design Guide to incorporate guidance for the selection of high-performance barriers used in new construction and rehabilitation projects; this guidance should specifically address the unique considerations of shielding commercial passenger vehicles from point hazards. (H-12-27)

To the American Bus Association, the National Motorcoach Network, and the United Motorcoach Association:

Alert your members to (1) the circumstances of this accident, (2) the existence of the Federal Motor Carrier Safety Administration's Safety Management Cycle, and (3) how the safety management process can positively influence carrier safety. (H-12-28)

Previously Issued Recommendations Reiterated in this Report

The National Transportation Safety Board also reiterates the following safety recommendations:

To the Federal Motor Carrier Safety Administration:

Implement a program to identify commercial drivers at high risk for obstructive sleep apnea and require that those drivers provide evidence through the medical certification process of having been appropriately evaluated and, if treatment is needed, effectively treated for that disorder before being granted unrestricted medical certification. (H-09-15)

Develop and disseminate guidance for commercial drivers, employers, and physicians regarding the identification and treatment of individuals at high risk of obstructive sleep apnea (OSA), emphasizing that drivers who have OSA that is effectively treated are routinely approved for continued medical certification. (H-09-16)

Require all motor carriers to adopt a fatigue management program based on the North American Fatigue Management Program guidelines for the management of fatigue in a motor carrier operating environment. (H-10-9)

Develop and implement a plan to deploy technologies in commercial vehicles to reduce the occurrence of fatigue-related accidents. (H-08-13)

To the National Highway Traffic Safety Administration:

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)