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NATIONAL TRANSPORTATION SAFETY BOARD
Public Meeting of September 16, 2008
(Information subject to editing)

Highway Accident Report
Truck-Tractor Semitrailer Rollover and
Motorcoach Collision with Overturned Truck
Interstate Highway 94
Near Osseo, Wisconsin, October 16, 2005
NTSB/HAR-08/02

This is a synopsis from the Safety Board’s report and does not include the Board’s rationale for the conclusions, probable cause, and safety recommendations.  Safety Board staff is currently making final revisions to the report from which the attached conclusions and safety recommendations have been extracted.  The final report and pertinent safety recommendation letters will be distributed to recommendation recipients as soon as possible.  The attached information is subject to further review and editing. 

EXECUTIVE SUMMARY

Between 1:58 a.m. and 1:59 a.m. on Sunday, October 16, 2005, an accident comprising two events occurred on Interstate Highway 94 (I-94) near Osseo, Wisconsin. The first event was the single-vehicle rollover of a truck-tractor semitrailer combination unit. The second event occurred when a motorcoach collided with the wreckage from the first event.

About 7:30 p.m. on October 15, 2005, a 22-year-old truck driver departed Munster, Indiana, on an approximately 436-mile-long trip to Minneapolis, Minnesota, driving a truck-tractor semitrailer operated by Whole Foods Market Group, Inc. By 1:58 a.m., the truck driver had completed about 323 miles of his trip. The combination unit was traveling westbound on I-94 near milepost 85, at a police-estimated speed of 63 to 69 mph, when the unit departed the right-hand travel lane and paved shoulder at an approximate 3-degree angle. The unit entered the earthen, sloped roadside and traveled approximately 535 feet. The driver steered to the left, and the combination unit reentered
the pavement and overturned onto its right side, sliding to a stop so that it blocked both westbound lanes and shoulders of I-94. The truck driver said that following the overturn, he turned off the ignition and was then thrown into the sleeper berth area by another impact.

About 3 hours before this accident, a group of marching band members from Chippewa High School left the University of Wisconsin near Whitewater on an approximately 225-mile-long trip back to Chippewa Falls, Wisconsin. The group was traveling in four motorcoaches and had completed about 195 miles of the return trip. The accident vehicle, a 1993 Motor Coach Industries DL-3 55-passenger-capacity motorcoach owned by Chippewa Trails, Inc., was in the lead. It was traveling westbound in the right-hand lane of I-94 at an estimated speed of between 64 and 78 mph when it collided with the bottom of the overturned combination unit about 1:59 a.m. The motorcoach driver and four passengers were fatally injured. Thirty-five passengers received minor-to-serious injuries, and five passengers were not injured. The truck driver received minor injuries.

During the investigation, the Safety Board identified the following major safety issues:

As a result of this accident investigation, the Safety Board makes safety recommendations to the Federal Motor Carrier Safety Administration, to the National Highway Traffic Safety Administration (NHTSA), and to Whole Foods Market Group, Inc.  The Safety Board also reiterates two safety recommendations to NHTSA.

CONCLUSIONS

  1. The weather did not cause or contribute to the accident.
  2. The mechanical condition of the truck-tractor semitrailer did not contribute to its departure from the roadway and subsequent rollover or to its being struck by the motorcoach; and the condition of the motorcoach’s steering, suspension, and tires did not contribute to its impact with the truck-tractor semitrailer.
  3. The motorcoach driver was not impaired by alcohol or drugs at the time of the accident.
  4. The emergency response was timely and adequate.
  5. Although the truck driver’s commercial driver’s license had been administratively suspended for failure to pay a fine, he had passed the licensing exam and had received an additional 280 hours of training by the motor carrier, indicating that he had the abilities needed to drive the truck-tractor semitrailer.
  6. Based on urine test results, the truck driver was not impaired by illicit drugs at the time of the accident; however, although there is no evidence that alcohol was a factor in the overturn of the truck-tractor semitrailer, specimens were collected from the truck driver too late to definitively exclude impairment due to alcohol use.
  7. The evidence, including an average vehicle speed of between 66 and 70 mph, the shallow angle of the truck-tractor semitrailer’s departure, and witness reports of the vehicle’s weaving on the road, suggests that the truck driver allowed the vehicle to drift from the roadway, indicating that the driver was operating while fatigued.
  8. The truck driver was asleep at the time of the accident because of the reduced quantity of his sleep; the reduced quality of his sleep due to alcohol consumption the previous night; and the circadian desynchronization he experienced due to his operating the truck in the early morning hours, when the body is predisposed to sleep.
  9. The Midwest distribution center of Whole Foods Market Group, Inc., provided an adequate off-duty period for the Osseo truck driver to obtain sufficient sleep, but he did not take full advantage of this opportunity.
  10. Had the truck-tractor semitrailer been equipped with technologies to detect fatigue, the systems might have prevented or mitigated the severity of the fatigue-related crash.
  11. The fatigued truck driver was alerted by the audible and/or tactile signal made by traveling over the rumble strips and/or grassy slope, turned the vehicle back toward the roadway, and lost control of the truck-tractor semitrailer.
  12. For fatigue management plans to be successfully implemented by motor carriers over time, Federal Motor Carrier Safety Administration oversight is needed.
  13. Although fatigue educational materials are becoming more widely available through the efforts of government agencies and many motor carriers, accident evidence suggests that some commercial drivers, like the Osseo truck driver, remain unaffected by the fatigue education message.
  14. The truck driver and the Midwest distribution center of Whole Foods Market Group, Inc., failed in their responsibilities to maintain status-of-duty records.
  15. Mandating the use of electronic on-board recorders by all interstate commercial vehicle carriers would ensure the availability of valid, accurate, and secure hours-of-service data, which could result in increased compliance with hours-of-service regulations.
  16. The side slopes parallel to Interstate 94 where the truck left the roadway were predominantly in the recoverable category; however, the circumstances of this accident, including a fatigued driver, a grassy slope with a lower coefficient of friction than the pavement, and night-time travel, made safely returning to the roadway or traversing to the bottom of the slope and stopping very difficult.
  17. Given the particular circumstances of the Osseo accident, an electronic stability control system would not have prevented the truck from overturning.
  18. Although the motorcoach driver did not wear corrective lenses on the night of the accident, as required, he was otherwise qualified and fit to drive the motorcoach.
  19. The darkness, the absence of lighting on the truck-tractor semitrailer, and the motorcoach driver’s use of low-beam headlights made it difficult for the motorcoach driver to see the overturned truck.
  20. The motorcoach driver saw the overturned truck and initiated braking prior to impact; however, even a driver with ideal vision most likely would not have been able to react to the unanticipated road hazard in time to slow the motorcoach sufficiently to alter the severity of the accident.
  21. The motorcoach driver’s early cataract formation most likely did not affect the outcome of this accident.
  22. Although the motorcoach driver’s schedule provides the possibility that his performance could have been impaired by fatigue, the visibility circumstances of the accident and the braking evidence indicate that he was awake and alert but could not see the wreckage in time to prevent the collision with the overturned truck.
  23. Improper maintenance of the brake system on the part of the motor carrier Chippewa Trails resulted in two out-of-adjustment drive axle brakes, which diminished the braking force available to slow the motorcoach but this condition likely did not contribute to the accident.
  24. A collision warning system with active braking might have prevented, or at least lessened the severity of, the motorcoach’s impact with the overturned truck.
  25. Because commercial vehicles, which typically have high centers of gravity, are prone to become unstable when they are hard-braked or steered suddenly to avoid a collision, collision warning system-equipped  commercial vehicles should also be equipped with an electronic stability control system addressing both roll and directional stability.
  26. Although in-vehicle warning systems offer opportunities for positive intervention to prevent accidents, providing multiple systems may overstress the driver’s response and decision-making capabilities.

PROBABLE CAUSE

The National Transportation Safety Board determines that the probable cause of the truck-tractor semitrailer rollover, the precipitating event in the accident sequence, and the motorcoach’s subsequent collision with the truck, was the truck driver’s falling asleep at the wheel, drifting from the roadway, and losing control of his vehicle. The truck driver was most likely fatigued because he did not take full advantage of adequate rest opportunities provided to him during his off-duty time and, as a result, obtained inadequate and disrupted sleep prior to the accident. The motorcoach collided with the overturned truck because there were insufficient visual cues to permit the driver to identify the truck wreckage in time to avoid the collision.

SAFETY RECOMMENDATIONS

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

To the Federal Motor Carrier Safety Administration:

  1. Develop and implement a plan to deploy technologies in commercial vehicles to reduce the occurrence of fatigue-related accidents.
  2. Develop and use a methodology that will continually assess the effectiveness of the fatigue management plans implemented by motor carriers, including their ability to improve sleep and alertness, mitigate performance errors, and prevent incidents and accidents.

To the National Highway Traffic Safety Administration:

  1. Determine whether equipping commercial vehicles with collision warning systems with active braking and electronic stability control systems will   reduce commercial vehicle accidents. If these technologies are determined to be effective in reducing accidents, require their use on commercial vehicles.

To Whole Foods Market Group, Inc.:

  1. Implement a comprehensive fatigue education program that requires management to ensure that employees understand the risks of driving while fatigued and comply with fatigue guidelines."

REITERATED RECOMMENDATIONS

To the National Highway Traffic Safety Administration:

  1. H-01-6
    Complete rulemaking on adaptive cruise control and collision warning system performance standards for new commercial vehicles. At a minimum, these standards should address obstacle detection distance, timing of alerts, and human factors guidelines, such as the mode and type of warning.

  2. H-01-7
    After promulgating performance standards for collision warning systems for commercial vehicles, require that all new commercial vehicles be equipped with a collision warning system.
     
     

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