******************************************************************************
"Lessons Learned" is a series of drop-in articles prepared by the NTSB for use 
in publications of other organizations.  An index of articles is available at
http://www.ntsb.gov/events/journalist/lessons/lessons.htm
07/2005
******************************************************************************


Lessons Learned from Accident Investigations 
Child Care Providers Urged to Check Vehicle Safety, Training and Health of Drivers 


A fatal accident in Memphis, Tennessee, that killed the driver of a van who had 
fallen asleep and four of the children he was transporting has lessons for child 
care centers across the country, according to the National Transportation Safety 
Board (NTSB).

“Our investigation uncovered a string of failures that led to this tragic accident,” 
said NTSB Chairman Ellen Engleman-Conners.  “It demonstrates once again that 
everyone in the transportation safety chain, including those who transport young 
children, plays a critical role in avoiding crashes, deaths and injuries.”

“This accident clearly points out the need for a comprehensive safety oversight 
system for child care transportation.  Without effective safety oversight, children 
are at risk,” Engleman-Conners added.

The crash occurred in April 2002, and involved a 15-passenger van, driven by a 
27-year-old driver who was transporting six children to school. The van was owned 
and operated by a private child care center.

The Safety Board report said a witness behind the van stated that the vehicle was 
traveling about 65 miles per hour when it drifted from the left lane, across two 
other lanes, and off the right side of the roadway. The witness said that she did 
not see any brake lights.

The van then overrode the guardrail and continued to travel along the dirt and grass 
embankment until the front of the van collided with the back of the guardrail and a 
light pole, and finally struck a bridge abutment at an overpass, the Safety Board 
said. The driver was ejected through the windshield and died from his injuries. Four 
children were killed, and two were seriously injured.

Investigators said none of the children in the van were wearing age-appropriate 
restraints. A 6-year-old passenger was restrained by a lap/shoulder belt, but was 
seated in the front seat, a location that the Safety Board has recommended that 
children under 12 not sit in. Another 6-year-old passenger and an 8-year-old passenger 
were not restrained in booster seats, which could have protected them from such injury. 
The two 10-year-old passengers and the driver were also unrestrained, contributing to 
the severity of their injuries.

The crash report also concluded that:

·	The driver had consumed marijuana on the morning of the accident and was under 
the influence of the drug at the time of the crash.
·	The diver fell asleep before departing the roadway; probably due to an 
undiagnosed sleep disorder.
·	If the center had used a vehicle built to school bus standards instead of a 
15-passenger van, the injuries might have been less severe.
·	Because the center did not comply with State laws and because the State did 
not provide adequate oversight of the center’s operations, the accident driver was 
able to transport children, even though he had not had a background check or medical 
examination.
·	Had drug testing been conducted, the accident driver’s drug use may have been 
detected and he may have been prohibited from transporting children.
·	There was a complete absence of driver and transportation oversight on the part 
of the center’s owner. 

In addition to not wearing age-appropriate restraints, the children in this accident 
were being transported in a 15-passenger van, a vehicle not built to school bus 
standards.  The Safety Board has consistently found in its investigations that when 
transporting children to school or school-related activities the safest form of 
transportation is a school bus or vehicle built to school bus standards. 

Fifteen-passenger vans are frequently used to transport child care students, school 
sports teams, van pools, church groups, and other groups.  Although they are involved 
in a proportionate number of fatal accidents compared to their percentage in the fleet, 
they are involved in a higher number of single-vehicle accidents involving rollovers 
than other passenger vehicles.

Various factors have been associated with 15-passenger van rollovers, particularly 
occupancy level and vehicle speed.  Because these vans are designed to carry 15 
passengers, the Safety Board is particularly concerned about the relationship between 
the vehicles’ occupancy level and their rollover propensity.  Fully loading or nearly 
loading a 15-passenger van causes the center of gravity to move rearward and upward, 
which increases its rollover propensity and could increase the potential for driver loss 
of control in emergency maneuvers. 

The Safety Board is convinced that the best way to maximize pupil transportation safety 
is to ensure that all vehicles carrying more than 10 passengers and transporting children 
to and from school, school activities and daycare centers meet federal school bus 
construction standards.

The Safety Board has recommended that the States implement a comprehensive child care 
transportation safety program.  Such a program should include:

·	Use of vehicles built to school bus standards or of multifunctional school 
activity buses.
·	A regular vehicle maintenance and inspection program.
·	A requirement that occupants wear age-appropriate restraints at all times.
·	A requirement that drivers receive a criminal background check and have a medical 
examination to determine fitness to drive.
·	Preemployment, random, post accident and “for cause” drug testing for all child care 
transportation providers; and the prohibition of anyone who tests positive for drugs from transporting children.
·	Review by an oversight agency of periodic driver background checks, medical 
examinations and drug test results.
·	A requirement that child car vehicles be labeled with the child care center’s and 
oversight agency’s names and phone numbers.

In the meantime, child care operators should voluntarily take these steps to help ensure the 
safety of the children in their care.

The full report is available from the NTSB’s Web site at www.ntsb.gov.