Remarks of Mark V. Rosenker
Acting Chairman, National Transportation Safety Board
before the
New Jersey Motorcoach Association
June 07, 2005


Good afternoon, and thank you Tom Dugan and Tom Jarbin for your kind invitation and warm hospitality. I am always happy to be here in New Jersey with my friends and colleagues in the motor coach industry.

I would like to take just a few moments to bring you up-to-date on 2 ongoing highway accident investigations involving motor coaches, and give you some insight into our investigative process.

Hewitt, TX
One accident that will likely come before the Board next month involves a motorcoach that crossed over the median of a divided highway in Hewitt, Texas on Valentines Day 2003. It occurred during a heavy rainstorm on a divided highway as the bus was making a lane change and braking to avoid stopped traffic ahead. The motorcoach driver lost control, crossing the grassy median, collided with a Chevrolet Suburban, killing 2 of the 3 occupants in the Suburban and injuring most of the 35 occupants on the motorcoach.

As I said, this accident occurred during a heavy rainstorm, so one of the first issues addressed by our investigators was how the motorcoach driver lost control of the vehicle. We did some pavement friction testing of the roadway and some additional testing of the actual tires from the motorcoach at the General Dynamics Company Tire Research Facility in Buffalo, New York. We also studied the sight distances and speed allowed on the roadway.

As you know, the Board is not only interested in the proximate cause of accidents, such as why the motor coach left the roadway, but delves deeper into other issues that affect the safety of the motorcoach occupants. In this accident, after the motor coach collided with the Suburban, it overturned on its right side and slid to rest against a concrete embankment. Compartmentalization works reasonably well in front and rear collisions but the Board has long recognized the limitations of compartmentalization in side impact and rollover accidents. In fact, enhanced protection of motorcoach passengers is on our Most Wanted List of Safety Improvements.

Finally, one more area of repeated concern to the Safety Board, and another item on our Most Wanted List, is the oversight provided by the Federal Motor Carrier Safety Administration via their compliance reviews. For example, this motor carrier had a Satisfactory rating from FMCSA. However, in calculating the accident rate as part of the compliance review, the FMCSA excluded accidents that occurred in intrastate operations from the accident rate calculations. Had these accidents been included, the motor carrier’s rating would have been Unsatisfactory. In addition, although this motor carrier was disqualified by the Military Traffic Management Command’s rating system, the FMCSA’s review system allowed it to continue to operate. This issue was address in the Board’s Victor, NY accident report last year and, as a result, FMCSA and the Military Traffic Management Command have entered into an agreement to share data and compliance reports. So there is some progress being made.

Turrell, AR
Another accident that the staff is currently working on involves a motorcoach accident in Turrell, Arkansas on October 9, 2004 in which a motor coach carrying 29 passengers left the roadway near an exit ramp and overturned. In this accident, the roof separated from the body, allowing passengers to be thrown from the vehicle. As a result, 14 occupants of the motorcoach were killed and another 16 injured. Of course passenger protection and roof structure integrity are critical issues in this ongoing investigation. However, it is important to note that this vehicle had previously been in a fire and the skin of the roof had been replaced and rust was found on some of the structural members.

This accident involved a driver that had been driving for approximately 8 hours and had been awake for approximately 19 hours. Did I say that the accident occurred at 5:02 am. So is it a fatigue accident? Maybe, and we’re still looking into this issue, but as you know this is the time of day that is statistically associated with drivers falling asleep, In addition, this particular driver was not accustomed to driving during these hours.

Another potential issue in this accident is the emergency response. As you know, the “Golden Hour” can have a critical impact on the survivability of injured passengers. Initial indications are that it took some 25 minutes after the 911 call for the correct fire department to be notified. In addition, our investigators found that there were no written policies or procedures for handling 911 calls in the county and only 2 of the 10 dispatchers have had any formal 911 training. So we are finding plenty of issues in both of these accidents to keep us busy.

In summary, I just want to say a few words about the Safety Board’s approach in investigating accidents, because it is unique. As you know we are charged by Congress to determine the cause of accidents and make recommendations to prevent future occurrences. It is a unique process and differs significantly from other organizations that investigate highway accidents. For example:

  • Second, we don’t make or enforce regulations, so we are not looking for rules that were broken like most regulatory agencies.
  • Third, we take a global outlook on the investigation by looking at all factors that may have contributed to the accident. I like to say that we are really in the business of determining what didn’t cause the accident. It’s really a process of elimination, because after you have examined each aspect of the accident by eliminating what didn’t cause the accident, then ultimately you are left with the few items that most likely did cause the accident. Thus, we end up with the resulting “probable” (or most likely) cause of the accident. It is a disciplined approach that has fared well over the years and helped the Safety Board become a successful and respected organization.

So when a tragic accident occurs it is the Safety Board’s job to make recommendations to prevent it from happening again. But we are not alone in our desire to prevent accidents. You are I are partners in this cause. So when accidents occur, my recommendation to you is to view them as an opportunity to do something different; find a maintenance improvement, implement a new operational policy, provide better training, embrace a new technology, etc. etc. but take action and do something -- because to do nothing is irresponsible and to rely on fate to prevent the next accident is complacency.

Therefore, my charge to you is, when accidents occur, which they inevitably will, take action, do something, to make your company a safer place for your passengers, your employees, your families, and your community.

Thank you.