Motorcoach Run-Off-The-Road Accident

8

Motorcoach Run-Off-The-Road Accident

Tallulah, Louisiana October 13, 2003

〔图〕插图

Highway Accident Report

NTSB/HAR-05/01

PB2005-916201

Notation 7711

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Contents

Acronyms and Abbreviations $\ldots$ v

Executive Summary vi

Factual Information .................................................................... 1

Accident 1

Synopsis .................................................................... 1

Accident Narrative 1

Injuries 6

Emergency Response .................................................................................................................................... 8

Damage ................................................................................................................................ 8

Motorcoach .................................................................................................................................................................................................... 8

Peterbilt Tractor Semitrailer .................................................................. 11

Driver Information $\ldots$ 12

Motorcoach Driver ..................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................

Peterbilt Tractor Semitrailer Driver .................................................................................................. 16

Vehicle Information $\ldots$ 16

Motorcoach .................................................................................................................................. 16

Peterbilt Tractor Semitrailer .................................................................................................. 18

Highway Information 21

General .................................................................................................................................... 21

Traffic 23

Rumble Strips .................................................................................................................................. 23

Motorist Service Facility and Weigh Station Locations 24

Operations Information 25

First Baptist Church of Eldorado .................................................................................................................................... 25

Alpha Trucking 27

FMCSA Carrier Oversight 28

Compliance Reviews 28

Roadside Inspections and Recordkeeping Requirements 29

Meteorological Information 31

Toxicological Information 31

Tests and Research 32

Motorcoach Seat Anchorages .................................................................................................................................. 32

Motorcoach Crashworthiness in Other Countries .................................................................................................. 35

Other Information 35

Selected Guidance to CDL Examiners on Medical Qualifications 35

Commercial Vehicle Inspection Programs .................................................................................................. 37

Analysis 40

Exclusions 40

Accident Discussion 41

Motorcoach Driver Performance ......................................................................................................................................................................................................................................................................................................................................................................................................................................................................................

Medical Factors $\ldots$ 43

Dietary Supplements ................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................

F: Safety Recommendations From the New Orleans Accident Investigation Report Pertaining to a Comprehensive Medical Oversight Program for Commercial Drivers

F: Safety Recommendations From the New Orleans Accident Investigation Report Pertaining to a Comprehensive Medical Oversight Program for Commercial Drivers

References

Factual Information

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〔图〕ARKANSASNMISSISSIPP20TallulahAccident SiteMP 168TEXASLOUISIANAGulfofMexico\n

Figure 1. Regional view of accident site.

〔图〕80652065Accident SiteLumaOTallulahMilepost 168RichmondEnglewoodON65602\n

Figure 2. Local view of accident site.

Factual Information

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Figure 3. Damaged motorcoach and tractor semitrailer on shoulder following accident. (Source: Louisiana State Police)

Witnesses who were traveling in vehicles behind the motorcoach for more than 30 miles prior to the accident reported that they noticed the motorcoach speed up, slow down, and drift from lane to lane. In a statement to the Louisiana State Police (LSP), one witness said the motorcoach had been “going side to side” for 2 miles before the collision. A second witness who had been driving eastbound on I-20 described the motorcoach as running off the right side of the road and then coming back and driving into the left lane. The second witness also reported that the motorcoach almost struck her vehicle, ran a pickup truck off the road, and nearly swerved into the path of a tractor semitrailer traveling in an adjacent lane.

One of the motorcoach passengers told Safety Board investigators$^{3}$ that he did not notice anything unusual about the driver or the trip before the accident. At the time of the accident, this passenger was seated five or six rows behind the driver. He recalled the sound of the crash but did not hear any noise before the impact.$^{4}$ Another passenger, seated behind the driver, reported to Safety Board investigators that she had been reading a map and observing the driver before the accident. She recalled that she felt that the speed of the

Factual Information

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〔图〕NORTHEastboundInterstate 20Center medianTire marksMotorcoachat-rest positionCombination vehicleMilepost 168at-rest posit

Figure 4. Accident site

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Figure 5. Motorcoach and Peterbilt tractor semitrailer at accident site. (Source: Louisiana State Police)

Factual Information

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Injuries

Eight motorcoach passengers were killed, and six passengers and the motorcoach driver sustained serious injuries. The Peterbilt truck driver was not injured.

Table 1. Injuries.

The eight passengers who sustained fatal injuries were reportedly found trapped between seats by emergency responders; they received serious injuries to the head, upper torso, internal organs, and extremities. These passengers were seated in rows 1, 2, 3, 5, 6, and 7 on the passenger side and rows 3 and 5 on the driver side. (See figure 6.) The six seriously injured passengers sustained blunt trauma to the head, upper torso, and extremities. Emergency responders reportedly found all six trapped between seats or in the aisle of the accident motorcoach forward of their precrash seating positions. The driver was the only restrained$^{8}$ occupant of the motorcoach, and he sustained serious injury to the left shoulder and lower right leg.

Factual Information

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〔图〕M-66:S、F-72:FF-74:S~M-65:FF-75:S3F-74:FF-76:F45F-81:FF-63:F6M-81:FM-70:s7F-68:FF-70:S*8Refreshment cooler(tied d

Figure 6. Accident motorcoach passenger seating chart.

Factual Information

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Board investigators that upon their arrival immediately after the accident, they found the seats “piled up” near the front of the coach, with passengers trapped among and underneath the seats. The emergency personnel stated that they had to pick the seats up and remove them from the motorcoach to extricate the passengers from the wreckage. Safety Board investigators found 16 seat frames (2 seats per frame) outside the motorcoach. Two seat frames remained inside the motorcoach on the passenger side and 6 frames remained on the driver side, for a total of 17 seats.

The passenger seat assemblies were composed of a seat frame containing two individual seat positions; each position had a seat bottom cushion, a seat back cushion, a headrest, an armrest, and a footrest (attached to the seat frame ahead). The seat frame was attached to an aluminum track on the interior sidewall by two C-clamps. A single pedestal slightly offset from the frame center was attached to a stainless-steel floor track by two T-bolt fasteners. The seating was designed so that the owner of the motorcoach could adjust the seating arrangement (number of seats and distance between rows). To move seats within the coach, the seat pedestal T-bolts had to be turned parallel in the track, the sidewall C-clamps had to be loosened, and the seats had to be removed or slid along the floor track. Then, once placed and arranged as desired, the seats had to be re-secured by tightening the C-clamps and turning the T-bolts nearly perpendicular in the track. (See figure 7.)

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Figure 7. Representative diagram of motorcoach passenger seat. On the LEFT: side view with close-up of pedestal, showing T-bolts and floor track attachment. On the RIGHT: front view with close-up of forward C-clamp and sidewall track.

Factual Information

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The 16 seat frames found outside the motorcoach had a total of 32 T-bolts, and the heads on 25 of these T-bolts exhibited substantial deformation. The heads on the remaining 7 T-bolts did not exhibit substantial deformation and were found to be aligned approximately parallel to the direction of the floor track. Fifteen of the 32 C-clamps were deformed or missing from the seat frames as a result of accident damage or damage caused while the passengers were extricated. On the 17 seats (8 seat frames) that remained in their original positions within the motorcoach, 5 C-clamps were deformed, 1 frame pedestal was torn from the floor track at the T-bolt, and the rest of the seat C-clamps and T-bolts were intact. (See figures 8, 9, and 10.)

〔图〕T-boltFloor trackT-bolt\n

Figure 8. Close-up of floor track and T-bolt fasteners.

〔图〕2INCHES\n

Figure 9. Damaged T-bolt in floor track.

Factual Information

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〔图〕RearForwardC-clampC-clamp\n

Figure 10. C-clamps attaching seat to sidewall track.

Peterbilt Tractor Semitrailer

The Peterbilt tractor sustained no observable collision-related contact damage. The semitrailer sustained damage from being struck by the motorcoach. The semitrailer's left wheel on the number four axle was moved forward 13 inches, and the left wheel on the number five axle was displaced 31 inches. The semitrailer's rear frame cross member on the left side was moved forward about 14 inches. (See figure 11.)

〔图〕14 inches13 inches0Area of impact31 inches\n

Figure 11. Topographic view showing variation between axle assemblies and crush damage to rear of semitrailer.

Factual Information

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The driver was not prescribed use of a Bi-level Positive Airway Pressure (BiPAP)$^{19}$ machine for his mild OSA.

According to the driver's medical records, on December 15, 1997, he visited a rheumatologist for “follow-up of degenerative joint disease involving his neck.” He was prescribed Ultram on December 30, 1997. The driver's physician's notes from August 30, 2000, stated, “The only time he [the driver] does get sleep is with the use of Ambien 3 times weekly.” Notes from an orthopedic surgeon dated November 1, 2001, stated, “Pain frequently awakens him and/or keeps him from sleeping.” Medical records dated May 29, 2003, document the driver's visit to a rheumatologist, noting, in part, “Joint pain... still on tramadol 6 a day and can tell it helps....” The rheumatologist prescribed two 50-milligram (mg) Ultram tablets to be taken three times a day and one 10-mg Ambien tablet to be taken every other day.

Just before the accident trip, on October 6, 2003, the driver visited his physician, who noted that the driver had

Chronic degenerative arthritis, chronic low back pain... sleep disturbance... advised when he is driving bus to be sure that he is not drowsy with the Ambien. Would caution and possibly avoid it. He states he is going to be out of town for 16 days on a bus trip....

Duty Status. About 8:00 a.m. on Sunday, October 12, 2003, the accident motorcoach departed Eldorado, Texas, for Shreveport, Louisiana. The motorcoach arrived in Shreveport about 5:00 p.m. According to the accident driver, he went to bed about 9:00 p.m. and slept until 6:00 a.m. on October 13. He told the LSP that he did not take his sleep medication (zolpidem) that evening and that he had slept “off and on” that night.

A 72-hour history for the motorcoach driver appears in table 2. It is based on interviews, the multicity tour itinerary, and evidence recovered from the motorcoach.

Factual Information

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Table 2. Motorcoach driver's 72-hour history summary. ( ~ is approximate)

Factual Information

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Table 3. Safety Board inspection of 1988 Peterbilt accident tractor brakes.

Factual Information

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Factual Information

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Table 4. Safety Board inspection of 1986 Fruehauf accident semitrailer brakes.

Factual Information

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Traffic

Louisiana Department of Transportation and Development (LADOTD) records from 2000 through May 2003 indicated that 21 accidents occurred within 2 miles of the accident scene, from milepost 166 to milepost 171 (in both the east- and westbound directions). The accidents resulted in no fatalities.$^{30}$

According to the LADOTD, the most recent preaccident traffic count in the vicinity of the accident was 17,193 vehicles per day. The count was taken 1 mile west of Tallulah, near milepost 169, on June 23, 2003. The available average daily traffic counts from 1995 through 2000, including both eastbound and westbound traffic lanes, are provided in table 5. The most recent data provided by the LADOTD for vehicle classifications on the interstate near the accident site indicated that buses account for 0.88 percent of vehicles, passenger vehicles and cycles for 37.76 percent, and trucks$^{31}$ for 61.36 percent.

Table 5. Available average daily traffic counts for accident area from 1995 through 2000. (Note: LADOTD did not provide figures for 1998 and 1999.)

Rumble Strips

According to the LADOTD, Louisiana is installing shoulder rumble strips on all its National Highway System roadways.$^{32}$ The Federal Highway Administration (FHWA) defines a shoulder rumble strip as

A longitudinal design feature installed on a paved roadway shoulder near the travel lane. It is made of a series of indented or raised elements intended to alert inattentive drivers through vibration and sound that their vehicles have left the travel lane.$^{33}$

On I-20, the rumble strips were rectangular-shaped, 7 inches wide, 16 inches long, and 0.5 inch deep, with a 5-inch space between the individual sections. The strips were milled onto the road surface 6 inches from the edge of the traveled way. In the area of the accident site, the rumble strips were located intermittently from the city of Monroe, Louisiana, east to the Mississippi State line. They were installed from Monroe to

Factual Information

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milepost 138 and from milepost 140 to milepost 149. The roadway sections from milepost 138 to milepost 140 and from milepost 149 to the Mississippi State line did not have rumble strips. The section of roadway including the accident site at milepost 167.9 did not have rumble strips.

According to the LADOTD, at the time of the accident, the State was preparing to begin a project to resurface the roadway and install rumble strips on the shoulder of I-20 beginning near milepost 158 to about milepost 171. The project was to begin with the opening of sealed bids from candidate contractors in November 2003 and to be completed in summer 2004. A resurfacing project had been conducted on the road in the area of the accident scene from 1989 to 1992.

In 2001, the LADOTD implemented a district-wide rumble strip installation project.$^{34}$ The section of I-20 from milepost 157 to the Mississippi State line, which included the accident site at milepost 167.9, was not part of the project. According to the LADOTD, this section was omitted because it was scheduled to be resurfaced in 2003 (see above), and installation of the rumble strips was delayed so the job could be included with the resurfacing project.$^{35}$ According to the LADOTD, rumble strip installation from milepost 157 to Tallulah (milepost 171) was completed in September 2004.

Motorist Service Facility and Weigh Station Locations

In the eastbound direction, truck stops, fuel stations, and other facilities were located along the interstate between Rayville, Louisiana, (milepost 138) and Tallulah (milepost 171). The facilities provided locations where drivers could stop and inspect the mechanical condition of their vehicles without stopping on the shoulder. (See table 6.)

Table 6. Motorist facilities along I-20 from milepost 138 to 171 (all in Louisiana).

Factual Information

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Table 7. Alpha Trucking's 24-month roadside inspection history.$^{53}$

Meteorological Information

The Vicksburg Tallulah Regional Airport Automated Surface Observing System, about 12 miles west of the accident site, was the closest official weather-observing system. At 10:53 a.m. on October 13, 2003, it reported clear conditions, a temperature of 75° F, and a 3-knot wind. On that day, the skies were cloudy, and the roadway was dry.

Toxicological Information

Within 2 1/2 hours of the accident, a blood specimen was drawn from the motorcoach driver at the emergency room where he was treated. The LSP laboratory results were negative for alcohol, marijuana, cocaine, phencyclidines, amphetamines, and opiates. The Safety Board also tested a specimen of blood from the driver.$^{54}$ The test results were positive only for the pain medication tramadol at a level of 0.023 µg/ml.

The tractor semitrailer driver consented to a postaccident breath alcohol test. The LSP administered the test at 12:25 p.m. using an Intoxilyzer 5000. The test resulted in a blood alcohol content percentage reading of 0.000. According to 49 CFR 382.303, the employer of a driver of a commercial motor vehicle operating on a public road in commerce is required to conduct alcohol and controlled substance testing on that driver if the vehicle is involved in a fatal accident. Safety Board investigators found no indication that Alpha Trucking completed any postaccident controlled substance testing on the tractor semitrailer driver.

Factual Information

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Tests and Research

Motorcoach Seat Anchorages

Multiple passenger seat frames, including those outside the intrusion area, were found separated from the floor and sidewall following the accident. Components of the seating system, including the sidewall and floor anchorage systems, a seat frame pedestal, and pieces of sidewall and floor track, were sent to the Safety Board's Materials Laboratory for testing and comparison with exemplars. In addition, Neoplan sent new exemplar T-bolts to the Materials Laboratory for testing and comparison purposes. Hardware from another seating manufacturer, National Seating, was also obtained for comparison. The hardware from National Seating provided a good basis for comparison because this manufacturer's seats were involved in a motorcoach accident in Burnt Cabins, Pennsylvania,$^{55}$ which was similar to the Tallulah accident. The two accidents involved motorcoaches of similar sizes and weights, which departed the roadway at similar speeds, and then impacted parked semitrailers. The passenger loading and the amount of intrusion were similar in the Tallulah and Burnt Cabins accident motorcoaches. Yet in the Burnt Cabins accident, unlike the Tallulah accident, all the seats outside the intrusion area remained secured. (See figures 12 and 13.)

〔图〕23\n

Figure 12. Exemplar T-bolt and floor track hardware for Neoplan (left) and National Seating (right).

Factual Information

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〔图〕23\n

Figure 13. Exemplar T-bolt top section and length measurement for Neoplan (left) and National Seating (right).

The Neoplan motorcoach seat assemblies were attached to the floor by a single pedestal, slightly offset from the center of the two bottom cushions, which was attached to the seat frame and fastened into the floor track with two T-bolts that were typically 6.5 inches apart on the base of the pedestal. The T-bolts flare out at the lower (head) end and, once inserted into the track, the bolts were turned slightly less than 90° to engage, then torqued down to secure the seat location. The seat frame was attached to a sidewall track using C-clamps at the front and rear of the seat frame, located about 9.75 inches apart. Each C-clamp was attached to the seat frame by a single bolt and secured to the wall by two separate pieces of metal clamped together, with another bolt just inboard of the aluminum sidewall rail.

Examination of the accident T-bolts showed that one or both sides of many of the bolts' heads were deformed downward, allowing the bolts to be pulled upward through the floor track. The National Highway Traffic Safety Administration's Federal Motor Vehicle Safety Standard (FMVSS) 207, “Seating Systems,” establishes the requirements for seats, their attachment assemblies, and their installation to minimize the possibility of seat failure caused by forces acting on the seat during an accident. The standard applies to passenger cars, multipurpose passenger vehicles, trucks, and buses.$^{56}$ The seating system

Analysis

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Highway Accident Report

ensure product quality and consistency and give consumers greater confidence that dietary supplements have the identity, strength, purity, and composition they are represented to have. The FDA published a proposed rule on March 13, 2003, and, as of January 28, 2005, was still evaluating the more than 1,600 responses it received from the public before issuing its final rule. On November 4, 2004, the FDA announced three major regulatory initiatives designed to further implement the Dietary Supplement Health and Education Act of 1994. The actions announced included providing a regulatory strategy, holding an open house meeting (held on November 15, 2004), and providing a draft guidance document for the industry entitled “Substantiation for Dietary Supplement Claims Made Under Section 403(r)(6) of the Federal Food, Drug, and Cosmetic Act.”$^{87}$

The Tallulah accident driver was advised by his physician not to take zolpidem while driving the motorcoach. Toxicological testing indicates that he probably was not taking his typical dose of tramadol at the time of the accident. He may have been using unproven herbal supplements as a substitute for zolpidem.

Although the Safety Board has concerns about the properties and possible interactions of herbal dietary supplements and how drivers' use of such substances as alternative treatments for medical conditions may affect their driving performance, it considers that, given the lack of information from the driver about when and how he was taking these supplements and the lack of available research concerning these substances, it is not possible to draw a definitive conclusion regarding their role in this accident. In addition, due to the nonregulation of the supplement industry, exact percentages and/or levels of the ingredients per supplement pill cannot be determined. The Safety Board therefore concludes that there is insufficient scientific research on, or standardization of, herbal dietary supplements to determine whether or how they might have contributed to this accident.

CDL Medical Examination

The accident motorcoach driver told Safety Board investigators that he renewed his CDL every 4 years,$^{88}$ but he had not received a medical examination since his employment in 1996 as a substitute bus driver with a local school system in Texas. Title 49 CFR 391.41 requires that motorcoach drivers undergo a physical examination for medical certification in order to drive a commercial motor vehicle. The motorcoach driver indicated he did not need a medical examination to drive the First Baptist Church of Eldorado's motorcoach. However, under FMCSA rules, the church was a for-hire carrier in commerce, and, therefore, the driver was required to undergo medical examination to drive the church's motorcoach.

According to 49 CFR 319.41(b)(5), if a person has an established medical history or clinical diagnosis of a respiratory dysfunction likely to interfere with his or her ability to control and safely drive a commercial motor vehicle, that person should not be certified

Analysis

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anchorage design in which a threaded vertical rod was placed within the seat pedestal and attached to a floor track (or the flooring itself) or a design in which a T-bolt fit into the opening of the floor track and then was turned perpendicular to provide securement (as in the Tallulah motorcoach).

Table 8. Previous Safety Board investigations involving motorcoach passenger seat anchorage problems.

No Federal regulation or standard requires large motorcoaches sold or operated in the United States to be equipped with active or passive occupant protection (other than for the driver). Standards or requirements for the strength and adequacy of passenger seat anchorage systems are also lacking.

Although the seat anchorage designs differed in the seven accidents (including Tallulah) investigated by the Safety Board, the causes of the seat anchorage problems in all cases were impact from unrestrained passengers and intrusion during the accident sequence. Many different seating system designs are used in motorcoaches operating in the United States; each manufacturer uses its own hardware and anchorage designs, and these designs are not required to meet any strength requirements or other standards. This lack of requirements for seating systems results in inconsistent occupant protection. The Safety Board concludes that because no performance standards are in place for motorcoach seat anchorages, some anchorage systems may be inadequately designed to withstand crash forces, which can lead to severe or fatal passenger injuries in an accident. The Safety Board believes the National Highway Traffic Safety Administration should develop performance standards for passenger seat anchorages in motorcoaches.

The Safety Board also investigated why those seating anchorages that were properly secured on the Neoplan accident motorcoach were not able to withstand the crash

Appendix D

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Table 1. General information on tested components.

Table 2. Hardness and strength information for tested components.

A longitudinal cross-sectional metallographic mount was made through one of the Neoplan accident T-bolts and one of the National Seating-supplied T-bolts. The microstructure of the Neoplan bolt consisted mostly of ferrite with bands of spherodized cementite and the National Seating-supplied T-bolt had a through-hardened tempered martensitic structure. Both T-bolts were forged/worked to the final shape. The structure indicated that the 1010 steel Neoplan T-bolt was not heat-treated to produce a hardened structure, compared to the National Seating-supplied T-bolts, which were.

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Appendix E

FMCSA Appendix G to Subchapter B, Minimum Periodic Inspection Standards

(The material for this appendix was obtained from the FMCSA Web site at

A vehicle does not pass an inspection if it has one of the following defects or deficiencies:

1. Brake System.

a. Service Brakes.

(1) Absence of braking action on any axle required to have brakes upon application of the service brakes (such as missing brakes or brake shoe(s) failing to move upon application of a wedge. S cam, cam, or disc brake).

(2) Missing or broken mechanical components including: shoes, lining pads, springs, anchor pins, spiders, cam rollers, push rods, and air chamber mounting bolts.

(3) Loose brake components including air chambers, spiders, and cam shaft support brackets.

(4) Audible air leak at brake chamber (Example ruptured diaphragm, loose chamber clamp, etc.).

(5) Readjustment limits. The maximum stroke at which brakes should be readjusted is given below. Any brake 1/4, or more past the readjustment limit or any two brakes less than 1/4, beyond the readjustment limit shall be cause for rejection. Stroke shall be measured with engine off and reservoir pressure of 80 to 90 psi with brakes fully applied.

BOLT TYPE BRAKE CHAMBER DATA

Appendix E

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ROTOCHAMBER DATA

CLAMP TYPE BRAKE CHAMBER DATA

WEDGE BRAKE DATA. -- Movement of the scribe mark on the lining shall not exceed 1/16 inch.

(6) Brake linings or pads.

(a) Lining or pad is not firmly attached to the shoe;

(b) Saturated with oil, grease, or brake fluid; or

(c) Non steering axles: Lining with a thickness less than 1/4 inch at the shoe center for air drum brakes, 1/16 inch or less at the shoe center for hydraulic and electric drum brakes, and less than 1/8 inch for air disc brakes.

Appendix E

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1. Lighting Devices.

All lighting devices and reflectors required by Section 393 shall be operable.

1. Safe loading.

a. Part(s) of vehicle or condition of loading such that the spare tire or any part of the load or dunnage can fall onto the roadway.

b. Protection Against Shifting Cargo -- Any vehicle without a front end structure or equivalent device as required.

1. Steering Mechanism.

a. Steering Wheel Free Play (on vehicles equipped with power steering the engine must be running).

STEERING WHEEL FREE PLAY

(on vehicles equipped with power steering the engine must be running).

b. Steering Column.

(1) Any absence or looseness of U bolt(s) or positioning part(s).

(2) Worn, faulty or obviously repair welded universal joint(s).

(3) Steering wheel not properly secured.

c. Front Axle Beam and All Steering Components Other Than Steering Column.

(1) Any crack(s).

(2) Any obvious welded repair(s).

d. Steering Gear Box.

(1) Any mounting bolt(s) loose or missing.

(2) Any crack(s) in gear box or mounting brackets.

e. Pitman Arm. Any looseness of the pitman arm on the steering gear output shaft.

f. Power Steering. Auxiliary power assist cylinder loose.

g. Ball and Socket Joints.

(1) Any movement under steering load of a stud nut.

(2) Any motion, other than rotational, between any linkage member and its attachment point of more than 1/4 inch.