2008 — Aug 8, Chartered Tour Bus Crash off Bridge on US Hwy 75, Sherman, TX — 17

lornajarrettblanchard August 8, 2008

— 17 National Highway Traffic Safety Administration. FARS 1975-2010 Fatality Analysis.

— 17 NTSB HAR. Motorcoach Run-Off-the Bridge and Rollover, Sherman, Texas, Aug 8, 2008.

— 16 Star-Telegram, Fort Worth. “Bus in crash…on road illegally; 16^th persons dies.” 8-9-2008

Aug 9, Star-Telegram: “A bus that crashed early Friday in Sherman — killing at least 16 people — shouldn’t have been on the road, federal and state records show.

“It was equipped with an illegal recapped tire on its front axle, which controls steering, crash investigators say. And the company that owned the vehicle, or a related company — investigators are still trying to sort out which — was still in operation more than a month after federal officials took steps to shut the operation down.

“Critics say they’re again frustrated that more hasn’t been done to improve motor coach safety on U.S. roads. “If these were regional airplanes that were crashing, and not motor coaches, Congress and everybody else would be on top of this to get something done,” said Jackie Gillan, vice president of the Washington-based Advocates for Highway and Auto Safety.
Saturday, the Sherman police department identified the bus driver as Barrett Wayne Broussard of Houston.

“The company, Angel Tours Inc. of Houston, that arranged transportation for 54 religious pilgrims from Houston to Missouri was banned from operating as an interstate carrier in June after federal officials found three critical safety violations. Even though the Houston bus crashed just south of the Oklahoma state line — not actually leaving Texas — it was considered an interstate motor coach because all the passengers bought tickets from Houston to Missouri, officials said.

“Angel Tours and a start-up motor coach company at the same address named Iguala Busmex also were not legally registered to operate motor coaches on Texas roads, state records show.
On May 1, the Federal Motor Carrier Safety Administration found that Angel Tours:

“Used a driver before receiving a pre-employment result.

“Failed to require a driver to prepare a vehicle inspection report.

“And used a driver not medically re-examined every 24 months.

“A total of $3,460 in fines was assessed May 8 for two of those charges, and on June 23, the company was ordered out of service.

“But on June 26, company owner Angel de la Torre filed an application for a new bus service, Iguala Busmex, at the same Houston address, federal records show. De la Torre could not be reached for comment. Calls to the offices of Angel Tours and Iguala Busmex were unanswered Friday morning and afternoon.

“That application is pending, and Iguala Busmex wasn’t yet legally authorized to carry passengers. Companies can’t legally operate a coach service until the federal government approves the application, according to federal rules.

“Critics counter, however, that many start-up companies operate for up to 18 months before their case is finally reviewed with an on-site visit. “It’s easy for them to continue operating with impunity,” Gillan said.

“Iguala Busmex’s federal application also shows that the company had not yet posted the minimum $5 million in insurance. State and federal officials say they’re still sorting through whether the bus that crashed belonged to Angel Tours or Iguala Busmex — but either way it was not allowed to operate.

“Bus was 2002 model.

“Police are being asked to stop any buses still being operated by Angel Tours or Iguala Busmex found on U.S. roads, said John H. Hill, Federal Motor Carrier Safety administrator.
Hill also said in a statement that his agency will “work with the proper authorities, if warranted, to vigilantly pursue civil and/or criminal violations relating to this incident.”

“The bus that crashed was a 2002 model built by Motor Coach Industries, or MCI, investigators said. It had paper license-plate tags that expire today, Sherman police said.

“National Transportation Safety Board officials declined Friday night to discuss the tags and said they were still trying to determine ownership. But they did discuss the recapped tire.
Recapped tires are essentially old tires equipped with a new layer of rubber tread. They are legal and are commonly used on tractor-trailers, buses and other large vehicles as a way to save money and preserve a tire’s life span. Federal rules allow recapped tires on passenger buses — but only on axles not involved in steering the vehicle. However, the bus that crashed in Sherman had a recapped Goodyear tire on its front axle, a violation of federal safety rules, said Debbie Hersman, a member of the National Transportation Safety Board. “If there is a loss of air pressure, or delamination of the tire, it’s much more difficult to control the vehicle,” Hersman said during a news briefing at Dallas/Fort Worth Airport. The other nine tires on the bus had their original tread, Hersman said. The left front tire was a Firestone.

“NTSB officials say they’re still investigating whether the blowout caused the crash. Survivors told police they thought a tire blew just before the driver lost control on northbound U.S. 75. The bus struck a guardrail and slid 180 feet before plunging 12 feet down an embankment and landing on its side.

“Violations of state law.

“The bus operator also was in violation of state law, records in Austin show. In Texas, motor coach companies that travel across state lines are required annually to submit a unified carrier registration number to the Texas Department of Transportation’s motor carrier division. Angel Tours registered a UCR in Texas in 2007 but allowed the registration to expire this year, department spokesman Robert Anderson said. Iguala Busmex has no number on file at the Austin office and also cannot legally operate, he said.

“The Federal Motor Carrier Safety Administration, in a company profile of Angel Tours, cited numerous safety violations during 26 inspections the past two years. Some of the violations occurred at Texas international points of entry and included problems with lights, tires and brakes, as well as driver errors such as speeding and logbook violations.
But federal and state officials lack the authority necessary to shut down businesses that fail inspections, critics say.

“Motor coaches also are long overdue for safety improvements to the bus itself, including stronger roofs, seat belts and glazed windows to prevent passengers from being ejected, they say.
A bill co-sponsored by U.S. Sen. Kay Bailey Hutchison, R-Texas, would require motor coach companies to make those changes, officials said. A hearing on that bill is scheduled for Sept. 18 in Washington. The bill would also require better driver training, on-board recorders, tougher roadside inspections and a national medical registry of drivers.

Angel Tours at a glance.

“The bus that crashed in Sherman, killing at least 15 people, was owned by either Houston-based Angel Tours or a new company at the same address called Iguala Busmex, officials say.
Owner: Angel de la Torre (also registered agent for Iguala Busmex, which is not yet approved as an interstate carrier).

Address: 1505 Telephone Road, Houston.
Online: www.angeltours.net
Buses: 6
Mileage per year: 500,000
Drivers: 6
Status: Taken out of service June 23.
Source: Federal Motor Carrier Safety Administration.” (Star-Telegram, Fort Worth, TX. “Bus in crash was on road illegally; 16^th persons dies.” 8-9-2008.)

NTSB: “Abstract: About 12:45 a.m. on August 8, 2008, a 56-passenger motorcoach was northbound on U.S. Highway 75 when it was involved in a single-vehicle accident in Sherman, Texas. The motorcoach had left Houston, Texas, about 8:30 p.m. on August 7, 2008, with a driver and 55 passengers onboard, en route to Carthage, Missouri. Before the crash, the motorcoach was traveling in the right lane of the four-lane divided highway. As the motorcoach approached the Post Oak Creek near Sherman, its right steer axle tire failed. The motorcoach departed the roadway, overrode a 7-inch-high, 18-inch-wide concrete curb, and struck the metal bridge railing. After riding against the bridge railing for about 120 feet, the motorcoach went through the railing and off the bridge. It fell about 8 feet and slid on its right side before coming to rest on the inclined earthen bridge abutment adjacent to the creek. As a result of the accident, 17 motorcoach passengers died, the motorcoach driver received serious injuries, and 38 passengers received minor-to-serious injuries.

“The major safety issues identified in the accident investigation included the need for tire pressure monitoring systems on commercial vehicles; the need for criteria for the selection of bridge railing designs; the lack of oversight of the Federal commercial vehicle inspections delegated to the states; the lack of motorcoach occupant protection systems; and the deficiencies in Federal safety oversight of new entrant motor carriers. As a result of its investigation, the NTSB makes recommendations to the Federal Highway Administration, the Federal Motor Carrier Safety Administration (FMCSA), the National Highway Traffic Safety Administration (NHTSA), the American Association of State Highway and Transportation Officials, the American Association of Motor Vehicle Administrators, and Motor Coach Industries, Inc. The NTSB also reiterates previous recommendations to the FMCSA and NHTSA.” (p. ii.)

“Executive Summary

“About 12:45 a.m., central daylight time, on Friday, August 8, 2008, a 2002 56-passenger Motor Coach Industries, Inc., motorcoach, operated by Iguala BusMex, Inc., was northbound on U.S. Highway 75 when it was involved in a single-vehicle, multiple-fatality accident in Sherman, Texas. The chartered motorcoach had departed the Vietnamese Martyrs Catholic Church in Houston, Texas, at approximately 8:30 p.m. on August 7, 2008, with a driver and 55 passengers onboard, en route to the Marian Days Festival in Carthage, Missouri. When the accident occurred, the motorcoach had completed about 309 miles of the approximately 600-mile-long trip.

“Before the crash, the motorcoach was traveling in the right lane of the four-lane divided high-way. As the motorcoach approached the Post Oak Creek bridge at a speed of about 68 mph, its right steer axle tire failed. The motorcoach departed the roadway on an angle of about 4 degrees to the right, overrode a 7-inch-high, 18-inch-wide concrete curb, and struck the metal bridge railing. After riding against the bridge railing for about 120 feet and displacing approximately 136 feet of railing, the motorcoach went through the bridge railing and off the bridge. It fell about 8 feet and slid approximately 24 feet on its right side before coming to rest on the inclined earthen bridge abutment adjacent to Post Oak Creek. As a result of the accident, 17 motorcoach passengers died; 12 passengers were found to be dead at the crash site, and 5 others later died at area hospitals. In addition, the 52-year-old driver received serious injuries, and 38 passengers received minor-to-serious injuries.

“The National Transportation Safety Board determines that the probable cause of this accident was the failure of the right steer axle tire, due to an extended period of low-pressure operation, which resulted in sidewall, belting, and body ply separation within the tire, leading to loss of vehicle control. Contributing to the severity of the accident was the failure of the bridge railing to redirect the motorcoach and prevent it from departing the bridge. The lack of an adequate occupant protection system contributed to the severity of the passenger injuries.

“The following safety issues are identified in this report:

The tire failure and the need for tire pressure monitoring systems on commercial vehicles;
The failure of the bridge railing and the need for criteria for the selection of appropriate bridge railing designs;
The lack of oversight of the Federal commercial vehicle inspections that are delegated to the states;
The lack of motorcoach occupant protection systems; and
The deficiencies in Federal safety oversight of new entrant motor carriers.” (p. ix.)….

“Investigators found no indication that the driver had been engaged in non-driving tasks, such as text-messaging or talking on a citizens band radio, loudspeaker, or cellular telephone, when the accident occurred. Postaccident interviews were conducted with 17 passengers; they indicated that there had been no distractions caused by passengers. At the time of the accident, the weather was clear and the roadway was dry.” (p. 1.)

“None of the passenger seating positions were equipped with occupant restraints. The driver’s seat was equipped with a 2-point lap seat belt, but the driver was not wearing it at the time of the accident.” (p. 4.)

“Emergency Response

“The City of Sherman Communications Center received initial notification of the accident at 12:45 a.m. from a motorist who saw the motorcoach depart the roadway. Police, fire, and EMS personnel were dispatched at 12:46 a.m. and arrived on the scene about 12:50 a.m. The City of Sherman and Grayson County Communications Centers worked to coordinate on-scene resources. The Sherman fire chief served as the incident commander, establishing a mobile command post near the accident site. Separate transfer points were established for ground ambulance and helicopter transport. Nineteen helicopter EMS response trips were executed by units from Sherman, McKinney, and Frisco, Texas. About 25–30 ground ambulances from nine different service departments responded. The injured were transported to nine regional medical facilities. Seven of the injured were transported to a local medical facility in Sherman; most were transported 30–40 miles to regional treatment facilities. Four were taken to two facilities in the Dallas, Texas, area, approximately 60 miles away; and one patient was transported to a facility in Fort Worth, Texas, about 90 miles away. The Dallas and Tarrant County Medical Examiner’s Offices also responded. By 1:08 a.m., within 23 minutes of the initial notification of the accident, the most critically injured patients had arrived at local medical facilities in Sherman and nearby McKinney, Texas. By 2:39 a.m., 1 hour 54 minutes after the accident, all the injured had been transported to medical facilities.

“Grayson County has an emergency response plan that includes all the county’s public safety agencies and area medical facilities. The response plan contains annexes with checklists and process descriptions for responding to mass casualty transportation accidents. During the emergency, the Sherman Fire Department activated the regional mutual aid plan to staff the ongoing work shift requirements for fire and rescue personnel called to the accident.” (p. 6.)

“Motorcoach Driver

“The 52-year-old male driver held a Texas class B commercial driver’s license (CDL) with a passenger endorsement, issued on December 15, 2005, and due to expire in 2010….

“Greyhound verified that it had employed the driver 13 years earlier. The driver told NTSB investigators that he had been terminated by Greyhound for failure to report for a medical examination. Information that the NTSB subpoenaed from Greyhound indicated that the driver had been terminated on March 21, 1995, because he tested positive for cocaine during a mandatory random drug test. NTSB investigators were unable to contact several of the other employers that the driver cited due to incomplete information and/or disconnected telephone numbers for the carriers….

“On his application for employment, the driver denied having had any accidents, traffic convictions, or forfeitures in the preceding 3 years. He also said that he had not been denied a license, permit, or privilege to operate a motor vehicle, and that he had not had a suspension or revocation of license, permit, or privilege to operate a motor vehicle. However, the driver’s history of motor vehicle violations obtained by the Sherman Police Department and the TxDPS showed that the driver had two speeding violations, one on March 20, 2007, and another on May 3, 2004. He was also convicted on August 16, 2001, of Driving While Intoxicated (DWI), following his refusal to submit to an alcohol screening test.

“The driver had undergone two roadside inspections in the 16 months preceding the accident. On May 2, 2007, and August 6, 2007, the driver was placed out of service for violation of 49 CFR 395.8(k)(2), because he did not have a record-of-duty status log covering the preceding 7 days in his possession at the time of those inspections. Additionally, for the May 2007 inspection, the motor carrier was cited for the driver’s failure to possess a valid medical certificate.” (pp. 6-7.)

“Driver Interview

“The driver was critically injured in the crash and gave only a brief statement to NTSB investigators on August 8, 2008, while he was in the hospital. When investigators attempted to interview the driver again on August 9, his medical condition had deteriorated such that he could not be interviewed then, or for the duration of the on-scene investigation.

“Two months later, in the presence of his legal counsel, the driver was interviewed. During the October 9, 2008, interview, the driver said…. that the first 4 hours of the trip were uneventful. In describing the accident event, the driver said that he first felt a sway or vibration with the bus and let off the accelerator because he was unsure of what was causing it. Then, within seconds, he heard an explosion, and the right front of the bus dropped. He stated that he ‘tried not to apply the brakes real hard.’ He tried to hold onto the steering wheel, but it quickly became impossible, and the bus drifted to the right….” (p. 9.)

“Driver’s Medical Certification

“At the time of the accident, the driver had an expired medical certificate. It had been issued on May 24, 2007, and had expired on May 24, 2008. The driver’s May 24, 2007, Medical Examination Report for Commercial Driver Fitness Determinations indicated ‘Yes’ to ‘High Blood Pressure’ and ‘Medications: Lisinopril.’ The report indicated ‘No’ to all other items under ‘Health History,’ including ‘Regular, frequent alcohol use,’ and ‘Narcotic or habit forming drug use.’ The driver’s blood pressure was noted as 108/78. The medical examiner noted that the driver met standards, but because of his taking high blood pressure medication, which would require periodic evaluation, the driver was qualified for 1 year, rather than the typical 2-year period.

“Review of the driver’s personal medical records revealed that he had been treated for high blood pressure, diabetes, and high cholesterol, as well as gastritis due to alcohol use. On May 9, 2008, the driver’s blood sugar was 293 milligrams per deciliter (mg/dL) (reference range 70–110), and his hemoglobin A1c (HbA1c) was 11.2 percent. The driver was advised at that time to begin using injectable insulin, and he received a prescription for insulin. The driver was also prescribed an oral antidiabetic medication at that time (metformin). Testing performed on a blood specimen obtained from the driver following the accident showed an HbA1c of 8.2 percent.

“Several bottles of prescription medications were among the driver’s personal effects recovered following the accident. According to the labels on the bottles, the medications and instructions for use were as follows: lisinopril, 20 mg, 1–2 daily; metformin HCL, 500 mg, once daily; and omeprazole, 20 mg, twice daily. In addition, a bottle of nonprescription Tylenol PM was found.”

“Toxicology Results

“Blood and urine specimens were obtained from the motorcoach driver at 4:26 a.m. (approximately 3.75 hours after the accident) and analyzed by the Federal Aviation Administration Civil Aerospace Medical Institute. The results were positive for benzoylecgonine

in the blood (0.242 micrograms per milliliter [μg/mL]) and urine (11.09 μg/mL), and for cocaine (0.171 μg/mL) and cocaethylene (0.293 μg/mL) in the urine.[1] Ecgonine methyl ester[2] was detected at unspecified levels in the blood and urine. Diphenhydramine was detected in the blood (0.0075 μg/mL) and at unspecified levels in the urine. No ethanol, cocaine, or cocaethylene was detected in the blood.” (pp. 9-10.)

“Survival Factors

“A 2-point lap belt was available at the driver’s seat. Investigators examined the belt and found it inoperative. The right side hasp portion of the belt was jammed in its retaining reel, preventing belt extension. The motorcoach was not equipped with passenger seat belts.” (p. 10.)

“Accident Reconstruction

“….The tire failure was initiated by the separating of steel belting materials, which led to belt edge lifting and shoulder rubber tearing, and ultimately to the detachment of belting and tread materials. During the belting and tread detachment phase, the tire casing ruptured, and an immediate inflation pressure loss resulted.” (p. 12.)

“Postaccident examination revealed that the right front tire on the steer axle was a retreaded tire. According to 49 CFR 393.75(d), ‘No bus shall be operated with regrooved, recapped or retreaded tires on the front wheels.’ In accordance with Federal regulations, the tire was identifiable as a retreaded tire.” (p. 18.)….

“Motor Carrier

“The motor carrier Iguala BusMex, Inc., was operating the Sherman accident motorcoach. The owner of Iguala BusMex also owned Angel Tours, Inc., a motor carrier that operated from the same address. Angel Tours had received operating authority in 1994 but was placed out of service by the FMCSA on June 23, 2008. Just over a month later, on July 27, 2008, the owner of

Angel Tours applied to the FMCSA for motor carrier operating authority under the name ‘Iguala

BusMex, Inc.’ As of the accident date, the FMCSA had not granted operating authority to Iguala

BusMex because its application was incomplete….” (p. 29.)

“As part of its application for authority to operate, Iguala BusMex was required to provide proof of the required $5 million insurance coverage (per 49 CFR 387.33). The FMCSA advised Iguala BusMex that its authority to operate would not be granted until proof of insurance could be verified. When the accident occurred, Iguala BusMex had not provided proof of the $5 million insurance coverage required to obtain operating authority; therefore, the FMCSA considered Iguala BusMex’s operating authority to be pending. According to the insurance company from which Iguala BusMex was seeking insurance, as of the date of the accident, the carrier had submitted paperwork to obtain insurance, but the insurance company had not reviewed the documentation; consequently, Iguala BusMex had no active insurance policy at the time of the accident. Review of the logbooks of Iguala BusMex bus drivers indicated that the company had conducted several trips in June 2008 without operating authority and in August 2008 with pending operating authority.

“On August 9, 2008, a day after the Sherman accident, the FMCSA issued an imminent hazard and out-of-service order for Iguala BusMex and Angel Tours and their officers and directors. The bases of the imminent hazard order were the operation of vehicles in a mechanically unsafe operating condition; the failure to ensure that the vehicles were properly and regularly inspected, repaired, and maintained; and the failure to ensure compliance with the Federal controlled substance and alcohol use and testing requirements, driver qualifications requirements, and driver hours-of-service requirements. Iguala BusMex and Angel Tours were required to cease all motor vehicle operations. The FMCSA also said that ‘Angel Tours’ continuity of operation through Iguala BusMex demonstrated a blatant disregard for previous FMCSA Out-of-Service Orders, which were issued based upon the company’s substandard safety record.” (p.31.) ….

“Analysis….

“Driver Issues. Toxicological testing performed on samples gathered about 3.75 hours after the accident detected cocaine and its metabolites in the driver’s blood and/or urine. One metabolite, cocaethylene, detected in the urine, is formed only when cocaine and ethanol are simultaneously present. The finding of cocaine and cocaethylene (which both have half-lives less than 90 minutes) in the urine, and the levels of benzoylecgonine in the blood and urine, suggest that the driver had used cocaine and alcohol approximately 5 hours prior to the accident.

“At the time of the accident, the driver had been on duty for 6 hours 45 minutes (not including a 1-hour-long work break). He had come on duty at 5:00 p.m. He had driven briefly between 6:30 and 7:00 p.m. to pick up passengers and then had had a 1-hour work break between 7:15 and 8:15 p.m. before beginning to drive again. He drove nearly continuously for the 4 hours 30 minutes between 8:15 p.m. and 12:45 a.m., when the accident took place. Therefore, the driver probably used cocaine and alcohol after reporting for work at 5:00 p.m.” (p. 46.) ….

“Commercial Vehicle Inspections

“….The Sherman accident motorcoach was inspected 8 days before the accident; the July 31, 2008, inspection was conducted at 5 Minute Inspections, located in Houston, Texas. The available records from that inspection show omissions and errors that concern the NTSB: specifically, no odometer reading or TxDOT number was entered, and the recorded date of the insurance expiration was incorrect. NTSB investigators visiting the facility noted that it did not have a service pit or a commercial vehicle lift capable of lifting a motorcoach. Without such equipment, it would be very difficult to conduct a thorough inspection of a motorcoach.

“Although investigators cannot be sure of the condition of the motorcoach when the inspection took place, the motor carrier purchased four new Ling Long tires for the motorcoach on July 29, just 2 days before the annual inspection. It seems likely that they were installed for the purpose of the inspection and that any tire rotation would have been done when the new tires were mounted, prior to the inspection. Thus, it appears that the retread tire was probably on the right steer axle when the inspection took place and that it was not identified as a retread during the inspection. As has been noted earlier in this report, Federal regulations prohibit the use of a retreaded tire on the steer axle of a motorcoach, and a thorough inspection should have detected this problem. The serious underinflation of the tag axle tires and the undersized wheel assemblies

on the tag axle also indicate that tire pressure measurements probably were not conducted during the inspection. Moreover, postaccident examination of the left axle brake drum and shoes found significant grease contamination with considerable buildup and caking, a condition that most likely had been in effect for much longer than 8 days but that was not identified during the inspection.

“The 5 Minute Inspections station inspected and passed another motorcoach owned by the accident motor carrier in early August 2008. The day after it was certified by 5 Minute Inspections, that motorcoach underwent a MCSAP-sponsored inspection conducted by the Missouri Highway Patrol and was placed out of service due to numerous violations. Vehicle violations found during the MCSAP inspection that should have been identified during the annual inspection included the following items: an out-of-adjustment brake on the right steer axle and general poor condition of the left steer axle brake, general poor condition of the right tag axle brake, and a missing or defective automatic brake adjuster.

“In March 2009, at the request of NTSB staff, the TxDPS Houston Regional Office visited the 5 Minute Inspections station and interviewed the inspector who had inspected the Sherman accident motorcoach. The TxDPS took no corrective action against 5 Minute Inspections.

“The NTSB concludes that the commercial vehicle inspections conducted by the 5 Minute Inspections station failed to identify safety deficiencies, and the TxDPS review of the station did

not identify any problems with its processes; therefore, at least in this instance, the state of Texas

vehicle inspection program for commercial motor vehicles did not provide adequate oversight of

the private garages it authorizes to conduct safety inspections. The NTSB is concerned that other

states may have similar problems with oversight of their inspection programs. The NTSB recommends that the FMCSA require those states that allow private garages to conduct FMCSA inspections of commercial motor vehicles to have a quality assurance and oversight program that

evaluates the effectiveness and thoroughness of those inspections.” (Pp. 56-57.) ….

“Safety Standards

“Seventeen people died and many more were seriously injured in this accident. In the event of an accident, the vehicle’s occupant protection system serves to mitigate the crash forces that cause injury. A comprehensive occupant protection system considers many aspects of the vehicle, including roof strength, window glazing, seat strength, and restraint systems and their anchorage strengths—all working together to protect occupants should a crash occur. Generally, the NTSB has found that passengers who remain in their seating compartments sustain fewer injuries, while ejected passengers are more likely to be killed. NHTSA motorcoach testing using crash test dummies has confirmed NTSB findings, showing that a lap/shoulder-belted dummy on

the far side of an impact had a much lower risk of sustaining injuries than an unrestrained dummy on the far side of an impact.” (p. 57.) ….

“The NTSB concludes that if NHTSA had implemented the requirements for motorcoach occupant protection systems following the issuance of Safety Recommendations H-99-47, -48, -50, and -51, fewer injuries and fatalities might have occurred because more occupants might have been retained within the accident motorcoach. Once again, the NTSB reiterates these safety recommendations, and they remain classified ‘Open—Unacceptable Response’.” (p. 60.) ….

“The majority of the seriously and fatally injured passengers incurred blunt force trauma to the head, neck, chest, and spine. There was evidence that several passengers’ heads contacted the luggage rack and, although investigators were unable to determine exactly when in the accident sequence passenger injuries took place, it is possible that serious head or neck injury resulted from the interactions between the passengers and the luggage rack. In addition, recent motorcoach rollover testing performed by NHTSA using crash test dummies has demonstrated the potential for serious head injury to unrestrained dummies due to passenger interactions with luggage racks. Lap/shoulder-belted dummies showed low risk for head injury and were retained within the seating compartment. Currently, there are no U.S. standards for luggage rack design that would help to reduce potential injuries during a motorcoach crash sequence. The NTSB concludes that the Sherman accident and recent motorcoach testing indicate that the lack of standards for overhead luggage racks on motorcoaches leaves passengers at risk of serious injury

from interaction with luggage racks in case of a crash. The NTSB recommends that NHTSA develop performance standards for newly manufactured motorcoaches that prevent head and neck injuries from overhead luggage racks.” (p. 61.) ….

“Motor Carrier Oversight

“….The NTSB is aware that the FMCSA has taken several steps since this accident to improve new entrant registration processes to increase its ability to identify a carrier, such as Iguala BusMex, that is attempting to evade FMCSA enforcement actions by becoming a reincarnated carrier. The FMCSA’s New Applicant Screening Program uses data to identify newly registered carriers that may have a history of enforcement problems. The screening process seeks matches between new registrants and information provided by previously registered motor carriers.

“The NTSB notes that the FMCSA is developing verification procedures intended to ensure that unfit operators do not receive operating authority; however, these measures were not in place at the time of the accident. Therefore, the NTSB concludes that at the time Iguala BusMex applied as a new entrant motor carrier, the FMCSA processes were inadequate to identify the carrier as a company that evaded enforcement action.

“The NTSB has reviewed information provided by the FMCSA concerning its new entrant screening program. The FMCSA material described how information about carriers is used to develop a score for a ‘suspect’ carrier, but it provides no description of a performance evaluation process designed to indicate whether the program is effectively preventing carriers with a history of evading safety requirements from continuing to operate. The GAO’s recent report on reincarnated carriers also makes no assessment of the new entrant screening program. Information available to the FMCSA, in the form of safety audits, compliance reviews, and roadside inspection results, could be used to identify unfit operators that were not targeted by the New Applicant Screening Program. This information could then be used to evaluate any limitations or shortcomings in the program’s ability to identify unfit carriers. The NTSB concludes that until the New Applicant Screening Program of the FMCSA contains a performance evaluation component capable of showing the program’s effectiveness in identifying carriers with a history of enforcement evasion and preventing them from operating, the screening program’s value cannot be accurately assessed. Therefore, the NTSB recommends that the FMCSA develop an evaluation component to determine the effectiveness of its New Applicant Screening Program.” (p. 62.)

“Revocation of Operating Authority

“Not only did Iguala BusMex begin operations without obtaining operating authority, but also a review of Angel Tours’ driver logs showed that several of the carrier’s drivers continued to operate after Angel Tours was placed out of service. In 2006, following the investigation of a multivehicle accident in Hampshire, Illinois, the NTSB issued Safety Recommendation H-06-17, which called for the FMCSA to

Establish a program to verify that motor carriers have ceased operations after the

effective date of revocation of operating authority. (H-06-17)

“The NTSB encourages the FMCSA to complete its actions with regard to improving oversight to identify and remove from operation unauthorized motor carriers.” (pp. 62-63.) ….

“Conclusions….

“5. The driver used cocaine and alcohol either during or shortly before starting the trip, and he may have been impaired by aftereffects from either or both drugs….

“7. If motor carriers cannot check the controlled substance testing backgrounds of prospective employees, they cannot make well-informed decisions when attempting to hire safe drivers.

“8. The difficulty in obtaining state records in connection with the controlled substance test results for the driver of the accident motorcoach in this case highlights the National Transportation Safety Board’s need for investigative access to a national database of positive drug test results.

“9. The tire on the accident motorcoach’s right steer axle experienced a puncture, and the resultant gradual pressure loss led to severe overdeflection, which resulted in sidewall, belting, and body ply separations within the tire.

“12. Failure of the tire on the steer axle resulted in the loss of control of the motorcoach.

“13. Underinflation of tires on commercial motor vehicles by even small margins can result in dangerous overloading of the tires.

“14. Because underinflated tires can lead to tire failure and because the currently approved methods of visual inspection or ‘thumping’ tires with a mallet are inaccurate, a tire pressure gauge should be used to accurately assess tire pressure.

“15. Until Motor Coach Industries, Inc., informs operators of the inaccuracies in the J4500 motorcoach maintenance manual, operators may be confused as to the proper tire pressures for these motorcoaches.

“16. If the driver had been aware of the motorcoach’s tire pressures, particularly the dangerously low pressure in the damaged right steer axle tire, then he would have had an opportunity to take corrective action, which might have prevented this accident.

“17. A higher performance bridge railing at the accident location might have prevented the motorcoach’s departure from the bridge.

“18. Bridge owners lack warrants to guide them in making high-performance bridge railing selections for specific project applications.

“19. The commercial vehicle inspections conducted by the 5 Minute Inspections station failed to identify safety deficiencies, and the Texas Department of Public Safety review of the station did not identify any problems with its processes; therefore, at least in this instance, the state of Texas vehicle inspection program for commercial motor vehicles did not provide adequate oversight of the private garages it authorizes to conduct safety inspections.

“20. If the National Highway Traffic Safety Administration had implemented the requirements for motorcoach occupant protection systems following the issuance of Safety Recommendations H-99-47, -48, -50, and -51, fewer injuries and fatalities might have occurred because more occupants might have been retained within the accident motorcoach.

“21. The failure of the luggage rack on the accident motorcoach impeded passenger egress and rescue efforts.

“22. The Sherman accident and recent motorcoach testing indicate that the lack of standards for overhead luggage racks on motorcoaches leaves passengers at risk of serious injury from interaction with luggage racks in case of a crash.

“23. At the time Iguala BusMex, Inc., applied as a new entrant motor carrier, the Federal Motor Carrier Safety Administration processes were inadequate to identify the carrier as a company that evaded enforcement action.

“24. Until the New Applicant Screening Program of the Federal Motor Carrier Safety Administration contains a performance evaluation component capable of showing the program’s effectiveness in identifying carriers with a history of enforcement evasion and preventing them from operating, the screening program’s value cannot be accurately assessed.” (pp. 64-65.)

“Probable Cause

“Recommendations

“New Recommendations

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

“To the Federal Highway Administration:

Establish, in conjunction with the American Association of State Highway and Transportation Officials, performance and selection guidelines for bridge owners to use to develop objective warrants for high-performance Test Level Four, Five, and Six bridge railings applicable to new construction and rehabilitation projects where railing replacement is determined to be appropriate. (H-09-17)

“To the Federal Motor Carrier Safety Administration:

Establish a regulatory requirement within 49 Code of Federal Regulations 382.405 that provides the National Transportation Safety Board, in the exercise of its statutory authority, access to all positive drug and alcohol test results and refusal determinations that are conducted under the U.S. Department of Transportation testing requirements. (H-09-18)

Require that tire pressure be checked with a tire pressure gauge during pretrip inspections, vehicle inspections, and roadside inspections of motor vehicles. (H-09-19)

Require those states that allow private garages to conduct Federal Motor Carrier Safety Administration inspections of commercial motor vehicles to have a quality assurance and oversight program that evaluates the effectiveness and thoroughness of those inspections. (H-09-20)

Develop an evaluation component to determine the effectiveness of your New

Applicant Screening Program. (H-09-21)

“To the National Highway Traffic Safety Administration:

Require all new motor vehicles weighing over 10,000 pounds to be equipped with direct tire pressure monitoring systems to inform drivers of the actual tire pressures on their vehicles. (H-09-22)

Develop performance standards for newly manufactured motorcoaches to require that overhead luggage racks remain anchored during an accident sequence. (H-09-23)

Develop performance standards for newly manufactured motorcoaches that prevent head and neck injuries from overhead luggage racks. (H-09-24)

“To the American Association of State Highway and Transportation Officials:

Work with the Federal Highway Administration to establish performance and selection guidelines for bridge owners to use to develop objective warrants for high-performance Test Level Four, Five, and Six bridge railings applicable to new construction and rehabilitation projects where railing replacement is determined to be appropriate, and include the guidelines in the Load and Resistance Factor Design (LRFD) Bridge Design Specifications. (H-09-25)

Revise section 13 of the Load and Resistance Factor Design (LRFD) Bridge Design Specifications to state that bridge owners shall develop objective warrants for the selection and use of high-performance Test Level Four, Five, and Six bridge railings applicable to new construction and rehabilitation projects where railing replacement is determined to be appropriate. (H-09-26)

“To the American Association of Motor Vehicle Administrators:

Revise the model Commercial Driver’s License Manual to stipulate that tire pressure be checked with a tire pressure gauge during pretrip inspections, vehicle inspections, and roadside inspections of motor vehicles. (H-09-27)

“To Motor Coach Industries, Inc.:

Correct any inaccurate tire pressure and gross axle weight rating information in the maintenance manuals of your J4500 motorcoaches and make electronic versions of the revised manuals readily available on your website; in addition, review the maintenance manuals of your other motorcoaches for similar errors and make appropriate corrections. (H-09-28)

“Previously Issued Recommendations Reiterated in This Report

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

“To the Federal Motor Carrier Safety Administration:

Develop a system that records all positive drug and alcohol test results and refusal determinations that are conducted under the U.S. Department of Transportation testing requirements, require prospective employers to query the system before making a hiring decision, and require certifying authorities to query the system before making a certification decision. (H-01-25)

“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)

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)” (pp. 67-69.)

(National Transportation Safety Board. Highway Accident Report. Motorcoach Run-Off-the Bridge and Rollover, Sherman, Texas, August 8, 2008 (NTSB/HAR-09/02; PB2009-916202). Washington, DC: NTSB, adopted Oct 27, 2009.)

Sources

National Highway Traffic Safety Administration. Partial Data Dump of Crashes Involving 10 or More Fatalities, by Year, Fatality Analysis Reporting System (FARS) 1975-2009 Final and 2010 ARF. Washington, DC: NHTSA, pdf file provided to Wayne Blanchard, 1-26-2012.

National Transportation Safety Board. Highway Accident Report. Motorcoach Run-Off-the Bridge and Rollover, Sherman, Texas, August 8, 2008 (NTSB/HAR-09/02; PB2009-916202). Washington, DC: NTSB, adopted Oct 27, 2009. http://www.ntsb.gov/doclib/reports/2009/har0902.pdf

Star-Telegram, Fort Worth, TX. “Bus in crash was on road illegally; 16^th persons dies.” 8-9-2008. Accessed at: http://www.saferoads.org/bus-crash-was-road-illegally-16th-person-dies

[1] NTSB fn 21: Benzoylecgonine is an inactive metabolite of cocaine, which is a central nervous system stimulant. Cocaethylene is an active substance formed in the body when cocaine and alcohol have been consumed together.

[2] NTSB footnote 22: Ecgonine methyl ester is a metabolite of cocaine.