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National Transportation Safety Board Releases Final Investigation Report Of The Victoria Bus Crash

On January 2, 2008, about 4:13 a.m., a 2005 Volvo 47-passenger motorcoach, operated by a 42-year-old driver and carrying 47 passengers, was proceeding northbound on U.S. Highway 59 (U.S. 59) about 5 miles south of Victoria, Texas, when the motorcoach driver partially drifted off the right edge of the roadway. The driver oversteered to the left to avoid leaving the roadway, resulting in the motorcoach coming back across both lanes, departing the left edge of the roadway, and partially entering an earthen median. The driver oversteered again to the right in attempt to reenter the roadway and then oversteered to the left a second time upon realizing the motorcoach had gone too far right. As a result of the final oversteer, the motorcoach yawed to the left, rotated counterclockwise, and overturned onto its right side. The motorcoach's right rear struck a guardrail as the motorcoach slid on its right side approximately 112 feet before coming to rest across the roadway. Within 5 minutes, and before emergency responders arrived on scene, a 2001 Ford Ranger pickup truck also traveling northbound on U.S. 59 struck the underside of the motorcoach forward of the rear axle. As a result of the initial motorcoach rollover, 1 passenger was fatally injured, and 46 passengers and the driver received injuries ranging from minor to serious. The driver of the pickup truck sustained minor injuries when the pickup truck struck the undercarriage of the motorcoach. (extract from report)

The final conclusions of the NTSB are:

CONCLUSIONS

  1. Weather was not a factor in this accident, nor were any highway defects found that would have caused or contributed to the accident.
  2. Although the vehicle did not meet the Federal Motor Vehicle Safety Standards (FMVSSs), the mechanical condition of the accident motorcoach was not a factor in this accident.
  3. The cause of the unrestrained passengers' injuries was their striking objects and other passengers inside the motorcoach, as well as their partial ejections from the motorcoach windows on the right side, most of which occurred when the motorcoach overturned.
  4. Although the driver's toxicological testing results were negative for alcohol and drug use and it was unlikely that the driver was under the influence of alcohol or drugs, the company's delay in collecting toxicological specimens prevents the National Transportation Safety Board from conclusively ruling out alcohol use as a factor in this accident.
  5. The motorcoach driver fell asleep and partially drifted out of his travel lane.
  6. Upon regaining awareness after partially drifting off the roadway, the accident driver overcorrected his steering, causing a loss of control of the motorcoach.
  7. Since the Federal Motor Carrier Safety Administration's fatigue video was created in 2000, scientific understanding of fatigue and fatigue countermeasures has improved, as well as distribution methods available for communicating this type of information, to include the Internet, which has the potential to reach even more commercial drivers.
  8. International Charter Services, Inc., failed to maintain operational control and safety oversight of Capricorn Bus Lines, Inc.'s, operations, including its drivers and vehicles, as required by the safety certification completed by International Charter Services, Inc., in its operating authority application (Form OP 1[P], Application for Motor Passenger Carrier Authority [section 4]).
  9. The Federal Motor Carrier Safety Administration had the authority to conduct a compliance review of Capricorn Bus Lines, Inc., but did not, thereby failing to assign the appropriate safety rating for an "at-risk" carrier to a carrier with serious safety violations.
  10. The Federal Motor Carrier Safety Administration, by its tacit approval of lease agreements for interstate passenger carriers that are broader in scope than the equipment leases regulated for cargo carriers, in effect provides a lower level of safety oversight to motor carriers that transport passengers than to those that transport cargo.
  11. Because the Federal Motor Carrier Safety Administration was aware during International Charter Services, Inc.'s, post accident compliance review that regular route service was being provided regularly without International's having applied for this type of operating certificate, and therefore the carrier was operating beyond its scope of authority, the Federal Motor Carrier Safety Administration should have taken enforcement action as required by the Motor Carrier Safety Improvement Act.
  12. Some motor carriers are circumventing the legitimate corporate succession processes established in 49 Code of Federal Regulations Part 365 by reapplying for Federal Motor Carrier Safety Administration interstate operating authority through the New Entrant Safety Assurance Process, a loophole that may permit unsafe passenger motor carriers to transfer operating rights to newly established motor carriers that may otherwise be prevented by 49 Code of Federal Regulations Part 365.
  13. The current Federal Motor Carrier Safety Administration compliance review process does not effectively identify unsafe motor carriers and prevent them from operating.
  14. Until the Federal Motor Carrier Safety Administration consistently enforces out of service orders, the New Entrant Safety Assurance Program will be unsuccessful in screening for and vetting carriers with a history of poor safety management controls that attempt to reenter interstate passenger operations as reincarnated carriers.
  15. There is no effective program or process currently in place to identify reincarnated carriers that reentered interstate passenger operations through the New Entrant Safety Assurance Process before the August 2008 implementation of the Federal Motor Carrier Safety Administration's New Applicant Screening Program.
  16. Without clear and specific guidance on appropriate lease agreements between OP 1(P) certificate holders and companies providing equipment for charters or regular route service, noncertificated companies could still be performing most, if not all, of the functions of an interstate passenger-carrying operator without regulatory oversight.
  17. When the owner of Capricorn Bus Lines, Inc., failed to declare importation of the accident vehicle with the U.S. Customs and Border Protection Agency upon entering the United States and subsequently obtained vehicle registration using a loophole in California's International Registration Plan program, he intentionally bypassed federal and state requirements for an imported vehicle to comply with the FMVSSs.
  18. Because many non-FMVSS-compliant motorcoaches found during this investigation still display U.S. jurisdictional (state) registrations and license plates, inspectors and law enforcement personnel do not have cause to suspect such vehicles of not conforming with federal law.
  19. Some states lack conformity when verifying FMVSS compliance during International Registration Plan apportioned vehicle registrations, permitting U.S. domiciled companies to operate non-FMVSS-compliant vehicles daily throughout the United States.
  20. Current federal safety oversight programs and importation regulations pertaining to passenger commercial motor vehicles are flawed because improperly imported (that is, not declared for importation) non-FMVSS-compliant motorcoaches operated by U.S. domiciled motor carriers on U.S. highways in commercial passenger service are not being identified, placed out of service, and subjected to current laws by the agencies responsible for the oversight of safety and importation: the Federal Motor Carrier Safety Administration, the National Highway Traffic Safety Administration, and the U.S. Customs and Border Protection Agency.
  21. Not having an electronic FMVSS verification process available to federal, state, and local law enforcement personnel to use during roadside vehicle inspections makes it difficult to verify whether passenger-carrying commercial motor vehicles meet the FMVSSs.
  22. The accident vehicle and all other non-FMVSS-compliant buses inspected by the Federal Motor Carrier Safety Administration should be detected during Federal Motor Carrier Safety Administration roadside inspections and compliance reviews and subsequently reported to the proper federal and state agencies for enforcement.
  23. The lack of a requirement for U.S.-domiciled carriers to certify the use of FMVSS compliant passenger vehicles in interstate commerce has created a gap in safety oversight, allowing non FMVSS compliant commercial passenger vehicles to be used by U.S.-domiciled carriers on U.S. highways.
  24. The Federal Motor Carrier Safety Administration's policy of not enforcing the requirement for passenger-carrying commercial motor vehicles to display a label of certification documenting the vehicle's compliance with all applicable motor vehicle safety standards and its failure to help identify and place out of service non FMVSS compliant vehicles undermines the National Highway Traffic Safety Administration's efforts as a partner safety agency.
  25. Current U.S. Department of Transportation policy allowing the Federal Motor Carrier Safety Administration to cross-reference the FMVSSs during a vehicle's inspection and, if the vehicle is not placed out of service, accept that as evidence of adherence to FMVSS performance standards, is faulty based on the Federal Motor Carrier Safety Regulations lack of performance testing during a vehicle inspection.
  26. The lack of a uniform, coherent definition for what constitutes an imported vehicle, in addition to a definition-of-use loophole in National Highway Traffic Safety Administration, Federal Motor Carrier Safety Administration and U.S. Customs and Border Protection Agency regulations has allowed some U.S. domiciled motor carriers to effectively bypass the importation laws and inspection processes established to verify conformance with the FMVSSs and register their Mexican manufactured vehicles within the United States.

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