NTSB - Testimony of Mark V. Rosenker

Remarks of Mark V. Rosenker
Acting Chairman, National Transportation Safety Board
Before the
New Jersey Motorcoach Association
June 5-6 2006

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 motorcoach industry.

I thoroughly enjoyed my visit with you about this same time last year and I thought I would take just a few moments to bring you up-to-date on some of the work the Board has done recently involving motorcoaches.

For those of you who were not here last year, let me briefly describe what the Safety Board is all about. Basically our job is to restore the confidence of the traveling public after a major transportation disaster. All of you are familiar with our role in aviation safety and the importance of having an unbiased, independent, investigatory agency determine the cause of aviation accidents and recommend solutions to prevent them from happening again.

When accidents occur, especially aviation accidents, public anxiety heightens and the fear of flying escalates. Although not logical, this perceived lack of public confidence can mean that fewer people are willing to fly. However, many flyers derive considerable solace in knowing that the Safety Board is in charge of the investigation, and as a result, most people continue to have confidence in the industry and continue to fly. They know that the NTSB will uncover whatever caused the accident and work to fix the problem.

The most poignant recent example was the potential hysteria following the American Airlines flight 587 that crashed into a Queens neighborhood on November 12, 2001, only 2 months after the 9/11 terrorist attacks that involved the hijacking of 4 aircraft. Fortunately, the public had sufficient confidence in NTSB to allow our investigation to proceed and the true cause of the accident to be revealed. So my point is that bad things happen, but it is NTSB’s job to find the problems, make the fixes, and restore the public’s confidence in our transportation systems.

Your job is much the same. Fatal motorcoach accidents are rare events. But each time one occurs your company works hard to make changes to prevent it from happening again so that the public will continue to have confidence in one of the safest modes of transportation. We are partners in this endeavor and our reputations depend on how effective we are in preventing accidents.

Last year I mentioned an accident we were working on that occurred in Hewitt, TX involving a motorcoach that slid off a wet highway in a heavy rainstorm. It collided with an SUV killing 2 and injuring 35. If you recall, the motorcoach was making a lane change and braking to avoid stopped traffic ahead. At this time last year we had not determined the probable cause or issued recommendations. The reason I would like to talk some more about this accident is because it is illustrative of how the Board operates and the thoroughness of our investigations.

So what did cause the accident? If you read the police report you will find that the cause was the driver operating too fast for conditions. Case closed, driver error, no safety improvements.

Now don’t get me wrong, the police have a tremendous job investigating thousands and thousands of highway accidents every day, so you cannot expect them to devote the time, energy, and resources that the Safety Board has on this or any other accident. In fact the Safety Board could not do what we do without the invaluable assistance of state and local law enforcement. However, if you read NTSB’s report you will find a much more complex analysis of the accident and a probable cause that points to systemic problems that, if corrected, could prevent future accidents.

For example, the Board found that a combination of low pavement friction and the low, but legal, tread depth of the rear tires of the motorcoach combined to create a situation where the coefficient of friction was between 0.16 and 0.20, -- about the same range as icy surfaces. Therefore, the Board recommended that the FHWA conduct research on the interaction between commercial vehicle tires and wet pavement surfaces to determine minimum frictional quality standards and tire requirements. We also made recommendations to Texas to inventory their highways to identify locations where highway speeds are too high to allow adequate stopping distances when the roads have poor vertical geometries, and low coefficients of friction. We also asked them to implement a plan for repaving roads with poor frictional qualities.

What we also found in this accident, after extensive testing, was a considerable difference between the coefficient of friction between the steer and drive axles, which caused instability of the vehicle during hard braking. In this case, the drive axle tires, which had a lower tread depth, lost lateral friction and began to slide rather than follow the front tires during the lane change maneuver. We have known for some time that lower tread depth on the rear tires of passenger vehicles create an inherent stability problem. This is why tire retailers will now always put the best tires on the rear of a passenger vehicle rather than on the front.

However, as you know, the Federal Motorcarrier Safety Regulations currently require that the tread depth for the front wheels of commercial vehicles be greater than all other tires. These requirements go back about 30 years but no one has studied whether this difference in tread depth requirements makes since. Therefore, we recommended that the NHTSA conduct testing on the effects of differing tread depths for the steer and drive axle tires and modify the tread depth requirements for each axle to reflect the result of the research.

In summary, because of the Board’s ability to do a thorough, independent, accident investigation, we found problems well beyond driver error including problems with the roadway surface, the roadway geometry, tire tread depth, and differential friction between the front and drive axles that could lead to preventing similar accidents in the future.

We currently have about half a dozen motorcoach accidents under investigation, but let me just take a moment to talk about one of the worst motorcoach tragedies in US history – the 23-fatal motorcoach fire that occurred during the hurricane Rita evacuation near Dallas, TX on September 23, 2005. In this accident, a 1998 MCI 54-passenger motorcoach operated by Global Limousine Inc. was traveling northbound on Interstate Highway I-45, carrying 44 passengers, when it became engulfed in flames. The passengers were from an assisted living facility in Bellaire, Texas, and many needed to be carried or assisted onto the motorcoach by firefighters and/or the nursing staff. In fact, the loading process took over 2 hours. After traveling about 18 hours in heavy traffic the right tag axle tire caught fire and quickly engulfed the motorcoach. The driver, 6 nursing staff-passengers, the parent of one of the nursing staff, and 14 patient-passengers were able to escape the fire. Unfortunately, 23 patients died in the fire, most of which were not ambulatory.

Motorcoach fires
Motor carrier oversight
Vehicle maintenance
Component part reliability
Driver qualifications, including proficiency with the English language
Driver fatigue
Fire suppression systems, and
Transporting elderly passengers with disabilities

In addition, the Safety Board will hold a public hearing on this accident, probably sometime in August of this year.

We have also picked up several additional motorcoach fires to compare and contrast with the accident that occurred near Dallas. For example, on August 16, 2005 a 2002 Van Hool 57-passenger-motor coach with 45 passengers aboard was traveling southbound on Interstate 91 near Meriden, CT when the driver noticed smoke coming from the right rear wheel well. He pulled off on the shoulder, exited the vehicle, and determined that the right rear wheels were on fire. He re-entered the motor coach and attempted to warn the passengers of the danger and tell them to exit the vehicle. However, the driver only spoke Chinese and the passengers were delayed in exiting the vehicle due to the lack of communication. The passengers ultimately deciphered what the driver was trying to express and exited the vehicle with no injuries. Initial indications are that this fire likely began in the engine compartment from an, as of now, unknown mechanical defect.

Just last month we picked up another motorcoach fire near Wilsonville, OR in which the source of the fire is very similar to the one near Dallas. This fire, however, happened on a 1998 Prevost, H345 motorcoach, so we know that this particular problem is not unique to one type of motorcoach. The motorcoach was carrying high school band members when the motorcoach driver pulled off to the side of the interstate after he smelled something and thought there was a problem with one of the vehicle’s tires. The right tag axle tire caught on fire and subsequently spread to the rear of the bus. Fortunately, all of the occupants got off the bus safely with no injuries reported.

As we have come to learn in investigating these and other accidents, motorcoach fires are not uncommon. In fact, there is about one every day of the week. However, injuries and fatalities are extremely rare, mostly because once the fire is detected, the motorcoach pulls over and the passengers exit relatively quickly. In the fire near Dallas the passengers were unable to exit quickly because they were not ambulatory. That is certainly a mistake we cannot repeat.

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:

First, we are not looking for blame or to make a criminal arrest, so our focus is very different than police investigations.
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 and 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.