Near Doswell, Virginia
May 31, 2011
NTSB Number: HAR-12-02
NTIS Number: PB2012-916202
Adopted: July 31, 2012
PDF
On Tuesday, May 31, 2011, approximately 4:55 a.m. eastern daylight time, a 2000 Setra 59-passenger motorcoach operated by Sky Express, Inc., occupied by a driver and 58 passengers, was traveling north on Interstate 95 in the right lane of the three northbound lanes near Doswell, Virginia. The motorcoach drifted from the highway to the right, struck a cable barrier, rotated counterclockwise around its vertical axis, overturned to the right, and rolled onto its roof. As a result of the accident, 4 of the 58 passengers were killed, 14 received serious injuries, and 35 received minor injuries. The driver sustained minor injuries and refused medical treatment.
The National Transportation Safety Board (NTSB) determines that the probable cause of this accident was the failure of the motorcoach driver to maintain control of the vehicle due to his falling asleep while driving because of fatigue resulting from acute sleep loss, poor sleep quality, and circadian disruption and the failure of Sky Express, Inc., management to follow adequate safety practices and to exercise safety oversight of the driver. Contributing to the accident was the Federal Motor Carrier Safety Administration's lack of adequate oversight of Sky Express, Inc., which allowed the company to continue operations despite known safety issues. Contributing to the fatalities and the severity of the injuries was the lack of a comprehensive occupant protection system, including systems for providing passenger restraint and for ensuring sufficient roof strength.
The accident investigation focused on the following safety issues:
Driver fatigue. The motorcoach drifted from the travel lanes because the driver fell asleep while driving. The motorcoach crossed the shoulder, passing over the rumble strip and onto an earthen area before striking the cable barrier. The driver awoke and steered to the left, back toward the travel lanes. Due to the driver's steering overcorrection and the cable barrier deflection, the motorcoach overturned and rolled onto its roof.
Motorcoach deficiencies in roof strength and occupant protection. The accident resulted in four fatalities, all of whom were initially seated on the passenger side of the bus in the region of maximum roof deformation. These four people died as a result of crushing injuries, as the motorcoach rolled over and the roof collapsed. Injuries occurred during the rollover when passengers were thrown from their seats and the survivable space decreased due to the substantial roof crush. Passenger restraints were not available on this motorcoach. The NTSB is concerned about the lack of Federal standards for occupant protection and roof strength on motorcoaches.
Federal Motor Carrier Safety Administration (FMCSA) failure to exercise adequate safety oversight of the accident motor carrier. In 2005, the interstate motor carrier operating this bus service sought operating authority from the FMCSA. The FMCSA passed the carrier in a new entrant safety assurance audit in early 2007, despite having identified deficiencies in the carrier's safety systems. During its 6 years in business as an interstate passenger carrier, the accident carrier was the subject of five FMCSA reviews of its compliance with safety regulations. According to the results of these reviews and additional information uncovered during the investigation, this carrier, Sky Express, Inc., repeatedly failed to fulfill the requirements of Federal safety regulations and did not ensure its drivers complied with safety requirements. Despite its recognizing Sky Express's safety deficiencies, the FMCSA did not remove the carrier's operating authority until the accident occurred.
Parties to the investigation were the FMCSA; the National Highway Traffic Safety Administration (NHTSA); the Virginia Department of Transportation; the Virginia State Police; and Setra North America, the motorcoach manufacturer.
As a result of the investigation, the NTSB makes three new recommendations to the FMCSA, reiterates previous recommendations to the FMCSA and NHTSA, reclassifies a previous recommendation to the FMCSA, and reiterates and reclassifies a previous recommendation to NHTSA.
As a result of its investigation of the Doswell, Virginia, motorcoach accident, the National Transportation Safety Board makes the following safety recommendations:
To the Federal Motor Carrier Safety Administration:
Establish an ongoing program to monitor, evaluate, report on, and continuously improve fatigue management programs implemented by motor carriers to identify, mitigate, and continuously reduce fatigue-related risks for drivers. (H-12-29) [This safety recommendation supersedes Safety Recommendation H-08-14.]
Incorporate scientifically based fatigue mitigation strategies into the hours-of-service regulations for passenger-carrying drivers who operate during the nighttime window of circadian low. (H-12-30)
As a component of your new entrant safety audits, review with each new entrant motor carrier a structured process, such as the Safety Management Cycle, to (1) identify the root cause of safety risks and (2) maintain an effective safety assurance program. (H-12-31)
The National Transportation Safety Board reiterates the following safety recommendations:
To the Federal Motor Carrier Safety Administration:
Require all motor carriers to adopt a fatigue management program based on the North American Fatigue Management Program guidelines for the management of fatigue in a motor carrier operating environment. (H-10-9)
Require all new motor carriers seeking operating authority to demonstrate their safety fitness prior to obtaining new entrant operating authority by, at a minimum: (1) passing an examination demonstrating their knowledge of the Federal Motor Carrier Safety Regulations; (2) submitting a comprehensive plan documenting that the motor carrier has management systems in place to ensure compliance with the Federal Motor Carrier Safety Regulations; and (3) passing a Federal Motor Carrier Safety Administration safety audit, including vehicle inspections. (H-03-2)
Change the safety fitness rating methodology so that adverse vehicle and driver performance-based data alone are sufficient to result in an overall unsatisfactory rating for the carrier. (H-99-6)
To the National Highway Traffic Safety Administration:
In 2 years, develop performance standards for motorcoach occupant protection systems that account for frontal impact collisions, side impact collisions, rear impact collisions, and rollovers. (H-99-47)
Once pertinent standards have been developed for motorcoach occupant protection systems, require newly manufactured motorcoaches to have an occupant crash protection system that meets the newly developed performance standards and retains passengers, including those in child safety restraint systems, within the seating compartment throughout the accident sequence for all accident scenarios. (H-99-48)
In 2 years, develop performance standards for motorcoach roof strength that provide maximum survival space for all seating positions and that take into account current typical motorcoach window dimensions. (H-99-50)
Once performance standards have been developed for motorcoach roof strength, require newly manufactured motorcoaches to meet those standards. (H-99-51)
The National Transportation Safety Board reclassifies the following safety recommendation:
To the Federal Motor Carrier Safety Administration:
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. (H-08-14)
Safety Recommendation H-08-14 is reclassified "Closed-Acceptable Action/Superseded" (superseded by Safety Recommendation H-12-29).
The National Transportation Safety Board reiterates and reclassifies the following safety recommendation:
To the National Highway Traffic Safety Administration:
Expand your research on current advanced glazing to include its applicability to motorcoach occupant ejection prevention, and revise window glazing requirements for newly manufactured motorcoaches based on the results of this research. (H-99-49)
Safety Recommendation H-99-49 is reiterated and reclassified "Open-Unacceptable Response" in this report.
