of Deborah Hersman
National Transportation Safety Board
2005 Motorcoach Expo
February 23, 2005
Good morning. Let me begin by thanking you for inviting me to participate in this year’s Motorcoach Expo. I personally have had a long and constructive association with the motorcoach industry. As you may know, prior to joining the NTSB, I was with the U.S. Senate Committee on Commerce, Science and Transportation. In that capacity, I worked closely with you on the development and passage of the Motor Carrier Safety Improvement Act of 1999, which created a new truck and bus safety administration within the Department of Transportation. I learned through that experience how focused your industry is on improving the already superb motorcoach safety record. I am delighted to again have the opportunity to work with you, this time as a Member of the National Transportation Safety Board, to continue our mutual quest to ensure the safety of our fellow citizens as they travel on our nation’s highways. I’d like to recognize Norm Littler and Clyde Hart who are in the audience today, these two gentlemen are excellent advocates for your industry, I have relied on their counsel when it comes to safety for many years.
I would also like to introduce three members of the NTSB's Office of Highway Safety who are with me today - - Joe Osterman, the office's director, Ken Suydam, one of the office's senior investigators-in-charge, and Larry Yohe, one of our most experienced vehicle specialists. I'm sure many of you know Joe, Ken, and Larry and have worked with them over the years. As a side note, some of you may not be aware that Larry is also the owner of a 1971 Eagle motorcoach that he has restored. Clearly some of our staff live and breathe motorcoaches, even on their off duty time.
For more than 35 years, the Safety Board's mission has been to prevent accidents. We conduct thorough, independent, and objective investigations and issue recommendations to correct the problems we discover. Together with organizations - - such as the UMA - - that provide specific expertise needed in particular investigations, our small agency of less than 430 employees has investigated thousands of aviation, railroad, marine, highway, and pipeline accidents.
Whenever I have an opportunity to speak to the motorcoach industry, I must thank organizations such as the UMA - - and all its members - - for your continuing efforts to improve motorcoach passenger safety on our roadways. Even though motorcoaches log an average of 28 billion passenger miles annually, your industry reflects one of the best, if not the best safety records in transportation. Although there were more than 43,000 deaths on our nations highways last year, fewer than 20 occurred in motorcoaches. A remarkable achievement indeed.
Even though our efforts have been successful - - we cannot become complacent. We must continue to reduce the number of accidents to the lowest level possible. Quite simply, the consequences of a motorcoach related accident are often more severe that an accident involving only passenger vehicles.
Just several weeks ago, on January 29, in Geneseo, New York, a motorcoach carrying 20 members of a collegiate girls hockey team crashed into the rear of a tractor semi-trail that was parked on the shoulder of the highway. Three occupants of the coach were killed along with the truck driver. The other coach occupants were all injured.
We are all here today to do our best to make sure that accidents - -such this one - - are prevented.
The Safety Board’s work in motorcoach safety continues to focus on several key recommendations that have yet to be implemented by the motorcoach industry or the Department of Transportation. I will address those issues with you today. Also, there are several new issues emerging from our recent accident investigations that you need to be aware of.
Throughout its history, the Board has focused on motorcoach safety and many of the current design and operating characteristics of these vehicles has been the subject of Safety Board recommendations.
Our first motorcoach investigation was the result of a charter coach overturn and fire on March 7, 1968, near Baker, California. Nineteen of the 30 passengers aboard were killed. In that accident the Board issued recommendations to improve the protection of motorcoach occupants, including recommendations for occupant restraints. As you may know, the Board believes that the correct solution to this controversial issue is to redesign the motorcoach occupant compartments so that occupants are retained within the compartment during a collision. Even though the interior compartments of motorcoaches, including the seats, have improved over the years, we are still faced with the problem that, 37 years since our first recommendation on this subject, one of the primary causes of passenger injury and fatalities in motorcoach accidents is that the passengers are thrown out of their seats or ejected when a bus sustains a front, side, or rear impact or rolls over.
The Safety Board again issued recommendations on this issue in 1999, and in 2001 added the issue of enhanced protection for bus passengers to our most wanted list of transportation safety improvements. In response to our recommendations, the National Highway Traffic Safety Administration has indicated that it will publish a notice of proposed rulemaking in 2006 that will address occupant protection issues on motorcoaches.
Although the Safety Board believes that progress on this critical issue has been extraordinarily slow, we hope that NHTSA’s efforts will lead to meaningful improvements in occupant protection standards for motorcoaches. We will continue to closely monitor NHTSA’s progress.
(Driver Medical Oversight)
Another Item on the Board’s list of most wanted transportation safety improvements is the prevention of medically unqualified drivers from operating commercial vehicles. This issue is founded in recommendations issued by the Safety Board to improve driver qualifications and the qualifications for commercial driver examiners.
The NTSB's report on the 1999 New Orleans bus crash that killed 22 people and injured 22 others highlights the importance of ensuring that fitness examinations for commercial drivers are properly conducted and adequately evaluate an individual's condition.
As you may remember, this accident was the fourth deadliest bus crash in U.S. history. A 55-passenger motorcoach enroute to Bay St. Louis, Mississippi, ran off the highway into a grassy side slope, crashed through a guardrail and a chain-link fence, vaulted over a paved golf cart path, and collided with a dirt embankment before finally coming to rest.
During our investigation, the Safety Board found that two years before the crash, the 46-year-old driver had been diagnosed with a terminal heart condition and suffered symptoms including impaired heart function, an enlarged heart, and congestive heart failure. In fact, the driver had been hospitalized several times for congestive heart failure. In addition, in July 1998, the driver was diagnosed with advanced kidney failure. By December 1998, he was receiving kidney dialysis three times a week.
Clearly, this individual should not have been driving a commercial vehicle. Yet, he was still able to obtain a valid commercial driver's license and pass a commercial driver's fitness examination in August 1998. As shocking as this situation is - - it is not unique. In fact, over the years, the Safety Board has examined many crashes involving drivers who did not meet the medical qualifications specified in the Code of Federal Regulations or who were unfit to drive commercial vehicles, and we continue to find these problems.
For example, on October 12, 2003, near Tallulah, Louisiana, a 1992 Neoplan motorcoach crashed into the rear of a tractor semi-trailer that was parked on the shoulder of the Interstate highway. Eight of the fourteen passengers aboard were killed and the others were injured. In this investigation, Safety Board investigators found that the 66-year old driver suffered from sleep apnea, and was taking 7 prescription medications and 14 herbal supplements at the time of the accident.
Based on the data uncovered during our New Orleans investigation, the Board concluded that the medical certification process for commercial drivers was ineffective and inadequate. As a result, we recommended that the Federal Motor Carrier Safety Administration (FMCSA) develop a comprehensive medical oversight program to revitalize and improve the program.
Flaws in the certification process can lead to increased highway fatalities and injuries for commercial vehicle drivers, their passengers, and the motoring public. Many drivers whose occupations and serious medical conditions are known to their employers, health care providers, and others are never reported to the appropriate motor vehicle licensing authorities, thereby potentially endangering the drivers themselves and the traveling public.
Enforcement authorities cannot, in most instances, determine the validity of a medical certificate during safety inspections and routine stops because of the absence of procedures or information sources to validate the medical certificate.
The inability to authenticate the information on a medical certificate hampers enforcement authorities in their ability to identify unfit drivers and place them out of service.
In the absence of a mechanism to track all medical certification examinations, a commercial driver with a serious medical condition who is denied a medical certificate by one examiner may be able to obtain a certificate from another examiner, thus subverting the purpose of the medical certification process.
The FMCSA has not established a tracking mechanism for reviewing prior applications for medical certification (although the FMCSA has indicated that it will research various approaches), nor have they updated medical certification regulations that determine whether drivers with common medical conditions should be issued a medical certificate.
While the FMCSA did publish a new medical certification form, it does not come with specific guidance or a readily identifiable source of information for questions on such examinations. Also, the FMCSA has not put into place a medical certification review process that prevents, or identifies and corrects, the inappropriate issuance of a medical certification. The FMCSA has noted an intent to address the ability of enforcement authorities to identify invalid medical certification and to prevent uncertified drivers from driving until an appropriate medical examination takes place. To support this effort, the FMCSA indicated to the Board that it plans to issue a notice of proposed rulemaking that will link the medical certificate of commercial drivers with the commercial driver’s license (CDL) process, however, we do not know when the rulemaking will occur. When the medical certificate and the CDL are linked, as we think they should be, law enforcement officials will be able to access a driver’s medical status at the roadside and take appropriate action.Additionally, FMCSA is establishing a Medical Review Board (MRB) to make recommendations for revising medical standards for commercial motor vehicle drivers (CMV). The MRB will also research requirements to enable future CMV driver medical standards to be developed. This is important because most of the medical standards currently in effect were adopted in the 1970s. Finally, the MRB will provide the FMCSA with an authoritative resource of medical expertise for making decisions on the medical and physical qualifications of individual commercial drivers, including drivers with multiple impairments. In September 2004, the FMCSA awarded two contracts – one to develop a Medical Registry and one to develop a Medical Review Board.
Even though the FMCSA is now moving forward on some of our recommendations regarding driver medical oversight, the Board is concerned about the speed at which these changes are being made. Remember that our recommendations were issued in 2001, and it was not until 2003 that FMCSA made any significant movement toward addressing the issues uncovered in the New Orleans investigation. Although the Safety Board has proposed significant changes to both the medical certification and drug-testing programs, we aren't proposing anything new.
There are successful examples of each of our proposals in several states and at the Federal Aviation Administration (FAA). FAA medical examiners are required to attend a training course, given a handbook of examination procedures, and regularly advised of regulatory changes. In addition, the FAA reviews and tracks all pilot examination forms. Our fellow citizens deserve a system that protects them on the highways as well. I urge each of you to work with the FMCSA, your associations and union representatives, and the states to ensure that these recommendations are implemented.
The Safety Board also expanded our examination of medical issues and drivers last fall when we issued a special investigation report on the medical oversight of non-commercial drivers. For that report, the Board investigated six noncommercial vehicle accidents in which a driver’s medical condition played a role.
There are approximately 191 million licensed drivers in the United States. Many of these drivers suffer from medical conditions that may severely affect their ability to operate a motor vehicle. These include visual impairments, cardiovascular disease, cerebrovascular disease (such as stroke), neurological diseases (such as epilepsy, dementia), respiratory diseases, renal disease, metabolic diseases (such as diabetes), psychiatric disease, and conditions brought on by the use of certain medications.
Although all 50 states have laws and regulations meant to prevent medically at-risk drivers from licensure, the Safety Board has determined, through accident investigations that current processes are often inadequate in doing so, and the risks are potentially great:
Statistics are not collected on the number of accidents caused by a driver’s medical condition, but to illustrate the potential scope of this issue, consider that in the United States there are approximately:
While these overall numbers are huge, one point that I want to emphasize is that the report did not conclude that complete classes of people should be penalized simply because a medical condition exists. With proper medical evaluation and appropriate treatment, many drivers can continue to drive safely with these medical conditions. As a result of last falls special investigation report the Safety Board identified the following safety issues:
As you can see, the medical issues for drivers are not confined to commercial vehicle operations.
Another issue, not unrelated to medical oversight is bus driver fatigue. Three years ago, NTSB Chairman Marion Blakey spoke to you about our recommendations, including our issues regarding fatigue. In 1995, the Safety Board issued a safety recommendation that urged the DOT, among other things, to require that commercial vehicle operators obtain at least 8 hours of continuous rest after driving 10 hours on duty. As you know, the FMCSA issued new hours-of-service rules on April 28, 2003, and they have recently issued an NPRM reinforcing the research behind those 2003 rules. The Safety Board closed our recommendation based on the 2003 rules, indicating that the FMCSA had substantially met the intent of the recommendation. The Safety Board also commended the FMCSA for issuing a rule that “should provide increased opportunities to rest and should result in increased driver alertness and fewer fatigue-related accidents on our roadways.” The Board noted that the current hours of service rule did not include motorcoach drivers. The FMCSA told us that they believed that because motorcoach operations were substantially different than trucking operations, applying the revised rules, which were developed primarily for truck drivers, to the motorcoach industry would be inappropriate. The Safety Board agreed. FMCSA indicated that additional research would be conducted to examine what rule changes would be appropriate for the motorcoach industry.
Recent Safety Board investigations demonstrate that the issues of fatigue in the motorcoach industry may be focused more on the inverted work-rest cycles experienced by many drivers, and issues associated with adequate rest for drivers during their off-duty time. For example, a recently completed Safety Board report on a motorcoach accident highlights this off duty rest issue.
On June 23, 2002, a 1998 MCI, 55-passenger motorcoach, operated by Arrow Line, Inc., a Coach USA subsidiary, was traveling eastbound between 60 and 63 mph on Interstate 90 near Victor, New York. The motorcoach, carrying 47 passengers, was en route from Niagara Falls, Ontario, Canada, to Waterbury, Connecticut. As the bus approached the Victor Exit 45 ramp, the vehicle departed the roadway and proceeded into the depressed grassy area between the eastbound exit and entrance ramps. The motorcoach then struck a W-beam guardrail, dragged approximately 700 feet of the guardrail across the eastbound entrance ramp, vaulted over the entrance ramp roadway, landed on the south side shoulder of the entrance ramp, rolled 90 degrees onto its right side, and slid to rest. The guardrail dragged by the motorcoach then struck three eastbound vehicles on the entrance ramp. Three occupants of these vehicles were uninjured, and six received minor injuries. Of the 48 people on the motorcoach, 5 passengers were killed; the driver and 41 passengers sustained injuries; and 1 passenger was uninjured.
The Safety Board determined that the probable cause of the accident was that the bus driver fell asleep while operating the motorcoach due to his deliberate failure to obtain adequate rest during his off-duty hours. The accident driver’s schedule for the 2 day’s preceding the accident trip included very little driving, and provided for sufficient time for the driver to obtain adequate rest. However, the board concluded that the driver had received less than 4-hours of interrupted sleep in the 51-hour period before the accident trip as a result of the driver deliberately spending his off-duty hours in a casino; he was therefore severely fatigued at the time of the accident.
The Board also commented to the FMCSA on their 2003 rules that the rules did not include a requirement for Electronic On-Board Recording (EOBR) devices. In the preamble to the 2003 rule, the FMCSA concluded that it “has neither the economic and safety data needed to justify an EOBR requirement, nor the support of the transportation community at large.” The Safety Board issued its first recommendation regarding on-board recording devices in commercial vehicles in its 1990 safety study, Fatigue, Alcohol, Drugs, and Medical Factors in Fatal-to-the-Driver Heavy Truck Crashes. The Safety Board recommended that the FHWA (later the FMCSA) “require automated tamper-proof on-board recording devices such as tachographs or computerized logs to identify commercial drivers who exceed hours-of-service regulations.” The Safety Board eventually closed this recommendation in 1998 as unacceptable because of the FMCSA’s lack of action. Recently, on September 1, 2004, FMCSA published an Advance Notice of Proposed Rulemaking requesting information “about the use of electronic on-board recording devices as a substitute for paper copies of driver’s records of duty status.”
Although the Board supports any activities that will lead to the adoption of rules to require EOBRs, we also note that it has been 15 years since the Safety Board’s initial recommendation on this topic, and that the technology is mature enough to use EOBRs as a substitute for paper logbooks. We urge again the FMCSA to expedite rulemaking that will require tamper-proof EOBRs to assist in enforcing HOS regulations.
In summary, the old issues of bus crashworthiness, driver medical oversight, and driver fatigue remain prominent on our radar screen. Unfortunately, several significant motorcoach accidents have occurred recently, and the Safety Board is expanding the motorcoach issues on our menu. Let me briefly review these accidents with you and the issues that have captured our attention.
On February 14, 2003, a Dina motorcoach with 35 passengers lost control and overturned on a congested highway near Hewitt Texas. Five passengers were killed and 9 others were injured. It was raining heavily at the time of the crash. In this investigation, Safety Board investigators are focusing on the condition of the pavement and the ability of the roadway to channel water away from the travel lanes. Also, the Board is looking at the over 35 year-old minimum tread depth requirements for commercial vehicle tires. Again, bus crashworthiness and driver medical oversight is an issue that we are exploring. The fatalities in the motorcoach occurred as a result of the overturn and occupants being ejected from their seating compartment, and the driver in this accident weighed over 400 lbs.
On October 1, 2003, a 1999 Ford E-45 with a Goshen 25 passenger body, was struck from behind by a tractor semi-trailer on a congested interstate in Hampshire, Illinois. Eight of the 21 passengers were killed. In this accident, among other issues, Safety Board investigators are examining the crashworthiness of second stage vehicle bodies, and their integrity during collisions.
On February 22, 2004, and again on September 19, 2004 separate accidents occurred at a US Customs and Boarder Protection checkpoint on the Northway in North Hudson, New York. The first accident involved a motorcoach. As a result of these accidents, the Safety Board issued an urgent recommendation to the Federal Highway Administration, US Customs and Boarder Protection, and the American Association of State and Highway Transportation Officials to improve the guidance and execution of traffic control designs for law enforcement checkpoints. I’m happy to report that all three organizations immediately began working on our recommendations.
As you can see, a common denominator in some of these accidents is the congestion of our nations high-speed arterial roadways, and the hazards this congestion creates.
On October 9, 2004, a motorcoach with 29 passengers, traveling from Chicago to Mississippi, ran off the road and overturned on a rural interstate in Turrell, Arkansas. This accident resulted in 15 fatalities. Again, driver fatigue issues may have played a role in this crash. Additionally, Safety Board investigators are working closely with MCI to examine repairs that were made to the roof of the motorcoach after it had been in a garage fire several years before the Turrell crash. As many of you know, the roof of this motorcoach was substantially crushed during the collision. Years before, following the garage fire, the coach was repaired. This repair included the replacement of roof panels. These new panels were riveted and glued on top of the original roof panels along both sides of the bus roof. The roof repair included drilling out the OEM’s rivets and then drilling new holes for the replacement rivets, however, when the repair was made, the new holes were not aligned with the old holes, resulting in many new holes to the roof structure. Our inspection of this repair revealed corrosion of several pillars and roof rails. We are continuing to work this issue.
On November 14, 2004, a motorcoach with 27 passengers, traveling on the George Washington Parkway in Alexandria, VA struck an arch shaped overpass. The accident crushed the roof along its right side longitudinal axis. Signs warning the driver of the height restrictions were readily apparent both along the highway and also within the motorcoach. Safety Board investigators are currently focusing on the drivers potential distraction from his use of a cell phone.
As you can see, the work continues. There is much left to be done on the issues of bus crashworthiness, driver medical oversight, and driver fatigue. Working together, the NTSB and the UMA can bolster the safety of our transportation system and ensure the safe travel of our fellow citizens. Our first responsibility is to the safety of the traveling public. With your cooperative spirit, we can continue to improve our transportation system and make it the safest in the world.