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Crashes in Baltimore, Maryland, and Chattanooga, Tennessee

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Crashes in Baltimore, Maryland, and Chattanooga, Tennessee Selective Issues in School Bus Transportation Safety: Crashes in Baltimore, Maryland, and Chattanooga, Tennessee Special Investigation Report NTSB/SIR-18/02 National PB2018-100932 Transportation Safety Board NTSB/SIR-18/02 PB2018-100932 Notation 57905 Adopted May 22, 2018 Special Investigation Report Selective Issues in School Bus Transportation Safety: Crashes in Baltimore, Maryland, and Chattanooga, Tennessee National Transportation Safety Board 490 L’Enfant Plaza SW Washington, DC 20594 National Transportation Safety Board. 2018. Selective Issues in School Bus Transportation Safety: Crashes in Baltimore, Maryland, and Chattanooga, Tennessee. Special Investigation Report NTSB/SIR-18/02. Washington, DC. Abstract: In November 2016, the NTSB began the investigation of two crashes involving school buses. Each crash was initiated when the driver lost control of the bus. In the November 1 crash in Baltimore, Maryland, the driver was epileptic and suffered a seizure. In the November 21 crash in Chattanooga, Tennessee, the driver was speeding while using a cell phone and ran off the road. In both cases, the school bus operators were private for-hire motor carriers. Although the specific safety issues differed, the crashes shared one common factor: poor driver oversight by both the school districts and the contracted motor carriers, which resulted in unsafe operation of the school buses. Between the two crashes, 12 people died and 37 were injured. The crash investigations focused on the following safety issues: school districts’ lack of oversight of student transportation providers; poor management of unsafe school bus drivers by the motor carriers and school districts; medically unfit school bus drivers; commercial driver license fraud; occupant protection in large school buses; and the benefits of electronic stability control, automatic emergency braking, and event data recorders. The NTSB made safety recommendations to the Federal Motor Carrier Safety Administration; the National Highway Traffic Safety Administration (NHTSA); the states of Florida, Louisiana, New Jersey, and New York; 42 states, the District of Columbia, and the territory of Puerto Rico—which lack requirements for lap/shoulder belts on large school buses; the state of Maryland; the Maryland Department of Education; the Maryland Motor Vehicle Administration; five school bus transportation associations; National Express LLC; seven school bus manufacturers; five electronic health record companies; and Concentra, Inc. The report also reiterates four recommendations to NHTSA and reclassifies a recommendation to the Baltimore City Public Schools. The NTSB is an independent federal agency dedicated to promoting aviation, railroad, highway, marine, and pipeline safety. Established in 1967, the agency is mandated by Congress through the Independent Safety Board Act of 1974 to investigate transportation accidents, determine the probable causes of the accidents, issue safety recommendations, study transportation safety issues, and evaluate the safety effectiveness of government agencies involved in transportation. The NTSB makes public its actions and decisions through accident reports, safety studies, special investigation reports, safety recommendations, and statistical reviews. The NTSB does not assign fault or blame for an accident or incident; rather, as specified by NTSB regulation, “accident/incident investigations are fact-finding proceedings with no formal issues and no adverse parties . and are not conducted for the purpose of determining the rights or liabilities of any person.” 49 Code of Federal Regulations Section 831.4. Assignment of fault or legal liability is not relevant to the NTSB statutory mission to improve transportation safety by investigating accidents and incidents and issuing safety recommendations. In addition, statutory language prohibits the admission into evidence or use of any part of an NTSB report related to an accident in a civil action for damages resulting from a matter mentioned in the report. 49 United States Code Section 1154(b). For more detailed background information on this report, visit the NTSB investigations website and search for NTSB accident numbers HWY17MH007 and HWY17MH009. Recent publications are available in their entirety at the NTSB website. Other publications information may be obtained from the website or by contacting: National Transportation Safety Board, Records Management Division, CIO-40, 490 L’Enfant Plaza SW, Washington, DC 20594, (800) 877-6799 or (202) 314-6551 Copies of NTSB publications may be downloaded at no cost from the National Technical Information Service, at the National Technical Reports Library search page, using product number PB2018-100932. For additional assistance, contact: National Technical Information Service, 5301 Shawnee Road, Alexandria, VA 22312, (800) 553-6847 or (703) 605-6000 (see the NTIS website) Contents Figures and Tables .................................................................................................................. v Acronyms and Abbreviations .............................................................................................. vii Executive Summary ............................................................................................................... ix 1 Introduction ......................................................................................................................... 1 2 School Bus Crash Investigations........................................................................................ 2 2.1 Baltimore, Maryland .......................................................................................................... 2 2.1.1 Crash Narrative ....................................................................................................... 2 2.1.2 School Bus Driver ................................................................................................... 7 2.1.3 Transit Bus Driver ................................................................................................. 11 2.1.4 Crash Analysis ...................................................................................................... 12 2.2 Chattanooga, Tennessee ................................................................................................... 13 2.2.1 Crash Narrative ..................................................................................................... 13 2.2.2 School Bus Driver ................................................................................................. 20 2.2.3 Crash Analysis ...................................................................................................... 23 3 Maryland Commercial Driver Licensing........................................................................ 26 3.1 Background ...................................................................................................................... 26 3.2 Baltimore School Bus Driver ........................................................................................... 27 3.2.1 Driver License Fraud ............................................................................................ 27 3.2.2 Facial Recognition Technology ............................................................................ 29 3.2.3 Other State Licensing Programs ........................................................................... 30 3.3 Safety Recommendations ................................................................................................. 31 4 School Bus Driver Fitness for Duty ................................................................................. 32 4.1 Federal and Maryland Medical Examination Requirements ........................................... 32 4.2 Medical History of Baltimore School Bus Driver ........................................................... 33 4.2.1 CDL Medical Examination History ...................................................................... 33 4.2.2 Emergency Medical Care ...................................................................................... 34 4.2.3 Safety Recommendations ...................................................................................... 35 4.3 Medical Condition Reporting to Driver Licensing Agencies .......................................... 37 ii NTSB Special Investigation Report 4.3.1 Categories and Methods of Referral ..................................................................... 37 4.3.2 Safety Recommendations ...................................................................................... 40 4.4 Electronic Health Records ............................................................................................... 41 4.4.1 High-Risk Medical Conditions and Driver Impairment ....................................... 41 4.4.2 Safety Recommendations ...................................................................................... 42 5 Oversight of Student Transportation Providers and Bus Drivers ............................... 43 5.1 Baltimore Crash ............................................................................................................... 43 5.1.1 School Bus Contractors ......................................................................................... 43 5.1.2 Baltimore City Public Schools .............................................................................. 44 5.1.3 Maryland State Department of Education ............................................................
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