NTSB calls for new coach regulations in wake of fatal crash

August 15, 2015

The Na­tional Transportation Safety Board called for four changes to bus and motorcoach regulations following a hearing into the 2014 cross-over crash of a double-trailer truck into a motorcoach carrying 45 passengers.

The Federal Express truck- tractor combination crossed a 58-foot-wide median on Interstate 5 near Orland in northern Califor­nia on April 10. The truck side- swiped a passenger car before hit­ting a Silverado Stages motorcoach head-on. The collision ruptured a fuel tank on the truck and sprayed fuel into the motorcoach. Both drivers and eight motorcoach pas­sengers were killed.

The coach was carrying 42 high school students and three adult chaperones to a weekend ori­entation at Humboldt State Uni­versity. Five students and the three chaperones died.

NTSB was unable to deter­mine a cause for the truck’s lane departure. All four recommenda­tions resulting from the investiga­tion, accepted by a 4-0 vote, ad­dressed motorcoach factors:

•     Lack of adequate fire perfor­mance standards for commercial passenger vehicle interiors

•     Lack of mandatory pre-trip safety briefings, which left pas­sengers unprepared to follow emergency exit procedures or to wear seatbelts

•     Need for improvements in vehicle design, including a second passenger door, to facilitate evacuations

•     Need for event data record­ers that can survive crashes and fires to assist in reconstructing investigations

Members of the safety board chastised the National Highway Traffic Safety Administration for failing to act on recommendations made nearly three decades ago to improve flame-resistance standards and install event data recorders.

“What is it going to take for NHTSA to step up to the plate?” asked member Robert L. Sumwalt.

Victor S. Parra, president and chief executive officer of the Unit­ed Motorcoach Association, ques­tioned the board’s focus on motor­coach factors in a crash caused by an errant truck with a fuel tank that exploded.

“Please understand that in in­vestigating this crash and fire, our objective was to find ways to pre­vent such crashes from occurring again or taking such a toll again,” said NTSB Chairman Christopher A. Hart. “The investigation brought to light double standards in regula­tions protecting motorcoach pas­sengers versus passengers in other modes of transportation.

“A passenger on an airline, for example, receives a safety briefing prior to departure. Fireproofing on airplanes is designed to withstand a major fire. There is emergency evacuation lighting. Because of these safety improvements in avia­tion — often resulting from NTSB investigations and recommenda­tions — when plane crashes are survivable, many more passengers now survive.

“Present regulations require none of these safety protections for motorcoach passengers. Today, we will ask why.”

No driver factors

Investigators could find no driver factors that could have caused the accident. The FedEx driver was 32 years old and experi­enced with no history of medical, alcohol, drug, licensing or viola­tion issues.

His activities over previous days ruled out fatigue as a possible factor. Witnesses identified no traffic or debris issues that could have caused the truck to swerve. Weather, cellphone use and the mechanical condition of the truck also were ruled out.

“Based on the driver’s lack of braking or other appropriate action prior to or during the crash se­quence — and witness accounts concerning the driver’s behavior and condition — he was unrespon­sive due to an unknown cause, which prevented him from control­ling his vehicle and led to the crash,” the NTSB findings stated.

Only one clue, which investi­gators could not pursue further, was found.

“The FedEx driver was in Weed, Calif., two hours before (the crash) and appeared to be clammy and pale,” testified Dennis Collins, an NTSB human performance fac­tors investigator.

“Physical evidence on the scene depicted a consistent path of shallow-angle departure for the truck...drifting with no steering or brake input...there was no reac­tion to stimuli. Staff also consid­ered whether a medical condition or medical incapacitation could explain the driver’s response,” Col­lins said.

“Unresponsiveness like this could potentially be associated with certain medical conditions such as a seizure or fainting as a result of dehydration.”

The driver was taking no pre­scription or over-the-counter med­ications and had no pre-existing medical condition, Collins said. Autopsy and toxicology reports could provide no findings.

“Staff cannot reach a conclu­sion on medical or physiological conditions as factors in this crash,” he said.

The conclusion, Collins said: “Due to an unknown cause, the truck driver was unresponsive, which prevented him from being able to control his vehicle.”

Fireball

Photographs and video taken by witnesses arriving on the scene show the cab of the truck and the front half of the motorcoach, a 2014 Setra, enveloped in a fireball.

“The catastrophic rupture of the truck-tractor fuel tank released fuel that sprayed into the interior of the motorcoach, resulting in fire and causing fatal and serious injuries to numerous motorcoach occupa­tions,” according to the findings.

“Federal Motor Vehicle Safety Standard 302 does not adequately account for modem vehicle interi­or components or conditions expe­rienced in real-world vehicle fires, nor does it include specific fire re­sistance material standards more appropriate for large commercial vehicles with increased passenger capacity,” the report continued.

“The lack of a pre-trip safety briefing led to confusion and panic during the motorcoach evacuation, as many passengers struggled to lo­cate and open the emergency exit windows. The quick-spreading fire and thick smoke prevented at least two passengers from extricating themselves from the motorcoach, resulting in their fatal injuries.”

About two minutes after the impact, a dash cam video showed passengers still attempting to evac­uate as the bus was filled was “smoke, heat and toxic gases,” said Joseph Panagiotou, fire initiation and propagation investigator.

He said the current standard for fire resistance in buses “involves a test that is representative of a small- scale ignition source like a ciga­rette. However, it does not simulate the ignition course that typically results in vehicles fires such as an engine fire or the forced fire result­ing from a collision.”

Panagiotou said the current standard for interior materials was developed in the 1970s.

“Today’s vehicles, particularly vehicles with high occupancies, have synthetic, lightweight materi­als such as plastics and foams that are more combustible than the ma­terials available when the test was developed,” he said. “The burning characteristics of these materials, in combination with thermal and toxic gas emissions, severely limit escape time and a passenger’s odds of survival.

“NTSB has been concerned about motorcoach and bus interi­ors for 30 years and has issued nu­merous recommendations to the National Highway Traffic Safety Administration,” he said. “The 302 standard has not been updated in that time. However, other modes of transportation, like rail and avia­tion, have made improvements to the standards.”

Parra, president of UMA, questioned the report’s emphasis on motorcoach factors.

“It’s puzzling — they dis­missed the truck as being a factor in any of this. We don’t know why the driver crossed the median and hit the bus, and they dismissed any factors about the truck although two of its fuel tanks exploded and spewed fuel into the bus,” he said.

“The fuel tanks are what caused the explosion and the fire. Instead of saying, ‘Let’s look at how we can better protect those fuel tanks in a collision,’ they said, ‘Let’s look at the bus.’”

Safety briefing

Surviving passengers told in­vestigators that they struggled to escape from the burning bus, said Ronald Kaminski, survival factors investigator. “Because a pre-trip safety briefing was not conducted, they did not know how to evacuate the bus.”

Although the front door of the bus was blocked by flames, emer­gency exit windows could have been used, he said. Due to confu­sion, some passengers left the bus through left-side windows, which placed them outside between the burning truck and bus.

“Had they exited from the right side of the vehicle they would have been farther away from the post­crash fire,” Kaminsky said.

He also noted the height of the leap from the exit windows to the ground. Some passengers “sus­tained minor injuries from the col­lision and the evacuation as they had to jump out windows that were seven feet off the ground.”

“A secondary door would allow passengers to stay low, avoid the fire-related heat and rapidly evacu­ate the vehicle,” he said. Improve­ments in emergency signage and lighting inside the coach also may have allowed faster evacuations.

A second door, on the right side of the coach ahead of the rear wheels, is fitted to many European motorcoaches.

“We support the recommenda­tions on safety briefings,” Parra said. “The idea of a pre-trip an­nouncement, so people know where the exits are, is certainly ap­propriate and sadly was not done on this trip.”

Black boxes

NTSB has been asking NHTSA since 1998 to mandate event data recorders in commercial vehicles, which would provide information for safety recommendations, said investigator Steven Prouty.

“There was limited informa­tion available for the reconstruc­tion of the crash event,” he said. Both vehicles were fitted with en­gine-data recording modules but these save a limited amount of data and both were rendered unreadable by the collision and fire.

“The lack of available event data recorders hindered the staff’s ability to determine the precise im­pact forces imparted on the vehicle or the occupants in this collision,” Prouty said.

“In 1998 the NTSB first intro­duced the issue of equipping commercial motor vehicles with recording devices. These recom­mendations were made to the trucking industry association but no action was taken.”

Recommendations

The board directed the new recommendation for more rigor­ous fire performance standards and a secondary door on new mo­torcoaches and buses to NHTSA. It recommended that the Federal Motor Carrier Safety Administra­tion require pre-trip safety brief­ings and update its website guid­ance on the mandated three-point restraint ruling that takes effect in November 2016.

NTSB reiterated its previous recommendation to NHTSA on “bus window retention and re­lease,” standards for onboard data recording and interior luminescent material marking emergency exits.

The recommendation for re­corders in heavy passenger vehi­cles was made to NHTSA in 1999, noted board member Sumwalt.

“To put it in perspective, my daughter had not even started school in 1999 and now she is about to graduate from college,” he said. “Clearly we want this to move and move quickly.”

Hart, the NTSB chairman, added: “We cannot undo the terri­ble toll of the crash that we dis­cussed today. We can, however, repeat our urgent message to regulators to take appropriate action to give motorcoach passengers a bet­ter chance of walking away from any such crash in the future.

“We urge NHTSA and the FMCSA to act on today’s new rec­ommendations, and for NHTSA to act on the recommendations reiter­ated today, to help prevent such crashes in the future, and to help prevent crashes that do nonethe­less occur from taking such a toll.” - WASHINGTON

Bus & Motorcoach NEWS, published August 15, 2015

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