NATIONAL

TRANSPORTATION

SAFETY BOARD

WASHINGTON, D.C. 20594

HIGHWAY ACCIDENT REPORT

PB2001-916203

NTSB/HAR-01/03

COLLISION OF CSXT FREIGHT TRAIN

AND MURRAY COUNTY SCHOOL

DISTRICT SCHOOL BUS

AT RAILROAD/HIGHWAY

GRADE CROSSING

CONASAUGA, TENNESSEE

MARCH 28, 2000

7415

Highway Accident Report

Collision of CSXT Freight Train

and Murray County School

District School Bus 

at Railroad/Highway 

Grade Crossing 

Conasauga, Tennessee

March 28, 2000

NTSB/HAR-01/03

PB2001-916203 National Transportation Safety Board

Notation 7415 490 LíEnfant Plaza, S.W.

Adopted December 11, 2001 Washington, D.C. 20594
National Transportation Safety Board. 2001. Collision of CSXT Freight Train and Murray County

School District School Bus at Railroad/Highway Grade Crossing in Conasauga, Tennessee, on March

28, 2000. Highway Accident Report NTSB/HAR-01/03. Washington, DC.

Abstract: On March 28, 2000, about 6:40 a.m. (sunrise was at 6:33 a.m.), a CSXT Transportation, Inc.,

freight train traveling 51 mph struck the passenger side of a Murray County, Georgia, School District

school bus at a railroad/highway grade crossing near Conasauga, Tennessee. The accident occurred as the

school bus was crossing the tracks at a speed of approximately 15 mph. During the accident sequence, the

driver and three children were ejected. Two ejected passengers received serious injuries and one was

fatally injured. The driver, who had been wearing a lap/shoulder belt that broke during the crash sequence,

received minor injuries. Of the four passengers who remained inside the bus, two were fatally injured, one

sustained serious injuries, and one, who was restrained by a lap belt, received minor injuries. The two train

crewmembers were not injured.

The following major safety issues were identified in this accident: 

ï The busdriverís performance. 

ï School district oversight, including busdriver monitoring and evaluation procedures and bus

routing.

ï Passive grade crossing safety, including previous initiatives related to passive grade crossing

and school bus safety.

ï Occupant kinematics and survival factors.

As a result of this accident investigation, the National Transportation Safety Board makes

recommendations to the States, the National Highway Traffic Safety Administration, the Federal Highway

Administration, the Georgia Department of Education, the National Association of State Directors of Pupil

Transportation Services, and the school bus manufacturers. The Safety Board also reiterates a

recommendation to the U.S. Department of Transportation.

The National Transportation Safety Board is an independent Federal agency dedicated to promoting aviation, railroad, highway, marine,

pipeline, and hazardous materials safety. Established in 1967, the agency is mandated by Congress through the Independent Safety Board

Act of 1974 to investigate transportation accidents, determine the probable causes of the accidents, issue safety recommendations, study

transportation safety issues, and evaluate the safety effectiveness of government agencies involved in transportation. The Safety Board

makes public its actions and decisions through accident reports, safety studies, special investigation reports, safety recommendations, and

statistical reviews.

Recent publications are available in their entirety on the Web at <http://www.ntsb.gov>. Other information about available publications also

may be obtained from the Web site or by contacting:

National Transportation Safety Board

Public Inquiries Section, RE-51

490 LíEnfant Plaza, S.W.

Washington, D.C. 20594

(800) 877-6799 or (202) 314-6551

Safety Board publications may be purchased, by individual copy or by subscription, from the National Technical Information Service. To

purchase this publication, order report number PB2001-916203 from:

National Technical Information Service

5285 Port Royal Road

Springfield, Virginia 22161

(800) 553-6847 or (703) 605-6000

The Independent Safety Board Act, as codified at 49 U.S.C. Section 1154(b), precludes the admission into evidence or use of Board reports

related to an incident or accident in a civil action for damages resulting from a matter mentioned in the report. 
iii Highway Accident Report

Contents

Acronyms and Abbreviations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . v

Executive Summary . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . vi

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

Accident Narrative . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1

School Bus . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1

Train . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4

Collision . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5

Injuries . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6

Medical and Pathological Information . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7

Toxicological Tests . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8

Survival Aspects . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8

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

Survivability . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9

Personnel Information . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10

School Bus Driver . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10

Train Crew . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11

School Bus and Wreckage Information . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11

School Bus . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11

School Bus Damage . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13

Train and Wreckage Information . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17

Train . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17

Train Damage . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17

Crossing Information . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 18

Highway . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 18

Railroad . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19

Operations Information . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19

School Bus Operations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19

Railroad . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 21

Management Information . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 21

Murray County Oversight . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 21

State Oversight . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 22

School Transportation Standards . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 22

Meteorological Information . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 24

Tests and Research . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 24

Lap and Lap/Shoulder Belts and Seat Coverings . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 24

Locomotive Event Recorder . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 24

Bus Video Recorder . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 25

Vehicle Speed . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 26

Audibility Tests . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 26

Auditory Warnings . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 27
Contents iv Highway Accident Report

Sight Distance . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 27

Accident Simulation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 28

Other Information . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 28

School Bus Transportation Safety . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 28

Reporting Near Misses at Grade Crossings . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 29

Railroad/Highway Grade Crossing Safety . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 29

In-Vehicle Warning Systems . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 34

Automatic Crash Notification Systems . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 35

Analysis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 37

General . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 37

Exclusions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 37

Accident Analysis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 38

Grade Crossings . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 40

Auditory Alerts . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 41

In-Vehicle Warning Systems . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 44

Grade Crossing Inventory and Hazard Prediction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 45

School Bus Routing . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 47

Safety Initiatives for Passive Grade Crossings and School Buses . . . . . . . . . . . . . . . . . . . . . . 47

Survival Factors and Occupant Kinematics . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 48

Emergency Response . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 55

Conclusions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 58

Findings . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 58

Probable Cause . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 60

Recommendations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 61

Appendixes

A: Investigation and Public Hearing . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 64

B: October 2000 Letter to the Governor of Tennessee From the Chairman, 

 National Transportation Safety Board . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .65
v Highway Accident Report

Acronyms and Abbreviations

AASHTO American Association of State and Highway Transportation 

Officials

ACN automatic crash notification

CDL commercial driverís license

CFR Code of Federal Regulations

CSC customer service center

CSXT CSX Transportation, Inc.

DOE Georgia Department of Education

DOT U.S. Department of Transportation

EMS emergency medical services

FHWA Federal Highway Administration

FMVSS Federal Motor Vehicle Safety Standard

FRA Federal Railroad Administration

GPS global positioning system

MADYMO Mathematical Dynamical Models

NASDPTS National Association of State Directors of Pupil Transportation 

Services

NCST National Conference on School Transportation

NHTSA National Highway Traffic Safety Administration

VCR videocassette recorder

WBPAS Web-based Accident Prediction System
vi Highway Accident Report

Executive Summary

On March 28, 2000, about 6:40 a.m. (sunrise was at 6:33 a.m.), a CSX

Transportation, Inc., freight train traveling 51 mph struck the passenger side of a Murray

County, Georgia, School District school bus at a railroad/highway grade crossing near

Conasauga, Tennessee. The accident occurred as the school bus was crossing the tracks at

a speed of approximately 15 mph. During the accident sequence, the driver and three

children were ejected. Two ejected passengers received serious injuries and one was

fatally injured. The driver, who had been wearing a lap/shoulder belt that broke during the

crash sequence, received minor injuries. Of the four passengers who remained inside the

bus, two were fatally injured, one sustained serious injuries, and one, who was restrained

by a lap belt, received minor injuries. The two train crewmembers were not injured.

The National Transportation Safety Board determines that the probable cause of

the collision was the school bus driverís failure to stop before traversing the

railroad/highway grade crossing. Contributing to the accident was the Murray County,

Georgia, School Districtís failure to monitor busdriver performance and its lack of school

bus route planning to identify hazards on school bus routes and to eliminate the necessity

of crossing railroad tracks. Contributing to the injuries of the school bus passengers were

incomplete compartmentalization and a lack of energy-absorbing material on interior

surfaces.

The major safety issues discussed in this report are the busdriverís performance;

school district oversight, including busdriver monitoring and evaluation procedures and

bus routing; passive grade crossing safety, including previous initiatives related to passive

grade crossing and school bus safety; and occupant kinematics and survival factors.

As a result of its investigation of this accident, the Safety Board makes

recommendations to the States, the National Highway Traffic Safety Administration, the

Federal Highway Administration, the Georgia Department of Education, the National

Association of State Directors of Pupil Transportation Services, and the school bus

manufacturers. The Safety Board also reiterates a recommendation to the U.S. Department

of Transportation.
1 Highway Accident Report

Factual Information

Accident Narrative

On March 28, 2000, about 6:40 a.m. (sunrise was at 6:33 a.m.), a southbound CSX

Transportation, Inc., (CSXT) 33-car freight train, en route to Atlanta, Georgia, collided

with the passenger side of a westbound Murray County, Georgia, School District school

bus at a railroad/highway grade crossing near Conasauga, Tennessee. The accident

occurred on Liberty Church Road in Polk County, Tennessee. The school bus was on its

morning route to pick up children and had entered Liberty Church Road from U.S. Route

411 and was making a loop to return to Route 411. As the school bus traversed the passive

grade crossing, it was struck.

The school bus was equipped with video recording equipment to monitor

passenger behavior on the bus. An examination of the videotapes found on the bus showed

that the school bus did not stop, as required, before attempting to cross the railroad tracks

on the day of the accident, nor had it stopped at this crossing on eight previous occasions.

During the accident sequence, the driver and three children were ejected. Two

ejected passengers received serious injuries and one was fatally injured. The driver, who

had been wearing a lap/shoulder belt that broke, received minor injuries. Of the four

passengers who remained inside the bus, two were fatally injured, one sustained serious

injuries, and one, who was restrained by a lap belt, received minor injuries. The two train

crewmembers were not injured.

School Bus

On the day of the accident, the driver made her regularly scheduled first pickup

about 6:35 a.m. The school bus was northbound on Route 411 when it turned right (east)

onto Liberty Church Road in Georgia (see figure 1). The busdriver usually picked up

passengers on Liberty Church Road, crossed the railroad tracks, and exited back onto

Route 411 southbound in Tennessee, approximately 0.2 mile from the Georgia State line.
Factual Information 2 Highway Accident Report

On its approach to the crossing, the school bus encountered two advisory signs.

The first was a round railroad advance warning sign1 with a placard that stated ìONE

LANE.î The second was a diamond-shaped warning sign2

 that stated ìLIMITED SIGHT

DISTANCE.î Beneath the second sign was a speed advisory sign3

 that stated ì10 MPH.î

Also at the crossing was a railroad crossing sign (crossbucks)4 on the right side of the

approach (see figure 2).

In a postaccident interview with the Tennessee State District Attorneyís Office on

March 28, 2000, the busdriver stated that she was ìcoming down the hill, came to a

complete stopî; looked left then right, left then right; pulled open the door and closed it.

She said that she looked in the rearview mirror to make sure all the children were sitting

down, then looked to the left and right again, and the train came out of nowhere. She

stated, ìIt was like it fell from the sky.î The busdriver refused any further interviews.

Figure 1. Map of Liberty Church Road area.

1 Sign W10-1 in the Manual of Uniform Traffic Control Devices.

2 This sign is no longer included in the Manual of Uniform Traffic Control Devices.

3 W13-1.

4 R15-1.

411

411

411

RAILROAD

ACCIDENT LOCATION

LIBERTY CHURCH RD

BUS PATH

X

LIBERTY CH. RD

LIBERTY CH. RD

GA TN

N
Factual Information 3 Highway Accident Report

In an interview after the accident, one of the passengers on the bus indicated that

the day of the accident was her second day riding the bus. She told the Tennessee State

District Attorneyís Office that she got on the bus, sat in the second row, and buckled her

lap belt.5 She could not remember whether the driverís window was open or closed. The

passenger stated, ìThe bus went down the hill and across the track without stopping, just

the same way the driver did the day before, without stopping.î She said she did not hear

the train horn.

5 The first two rows of seats on the bus were equipped with lap belts at each of the three seating

positions so that child restraint systems could be used for small children requiring them.

Figure 2. Scene diagram.

10 MPH

0 15' 30' 60'

Liberty Church Road

N

Conasauga, Tennessee

Source: National Transportation Safety Board

Rail road crossing sign

(MUTCD R15-1)

Rail road crossing sign

(MUTCD R15-1)

Approach path

of school bus

Approach path

of train

LIMITED

SIGHT

DISTANCE
Factual Information 4 Highway Accident Report

Train

Train S-213-25 was holding at the Ocoee siding,6 approximately 9.5 miles north of

Liberty Church Road, when the conductor and engineer were called on duty at 2:20 a.m.;

they arrived at the siding about 4:00 a.m. Upon arrival, the conductor released several

handbrakes on the cars as the engineer inspected the single locomotive. The engineer

conducted a set-and-release test of the airbrakes,7 then pulled the train to the south end of

the siding and, using the train brakes, stopped it as a way of measuring the effectiveness of

the brakes. The train continued to hold at the siding until approximately 6:18 a.m., when

the crew received a ìmedium clearî8 signal from the dispatcher-controlled signal at the

south end of the siding. The locomotive event recorder data indicated that the train moved

out of the siding and accelerated after the last car was on the main track. The crew

encountered a ìclearî9 signal at each subsequent signal location prior to the accident site.

After passing a wayside defect detector,10 the crew received an automated voice

radio transmission from the detector indicating the train had no defects. The detectorrecorded time was 6:25 a.m. and the train speed was 35 mph. The train increased speed to

56 mph while traveling on a descending grade. Thereafter, as it ascended a 3,173-foot

grade, its speed decreased gradually to about 51 mph. The locomotive horn and bell were

sounded at several grade crossings prior to reaching Liberty Church Road, according to

the locomotive event recorder.

As the train approached Liberty Church Road, the engineer stated that he saw the

bus approaching the crossing and yelled, ìHey! Hey!î The conductor jumped up and both

crewmembers were concerned about the action of the bus. The conductor said that the

yellow bus was illuminated by the sunlight and he noted road dust swirling behind it. The

engineer said that he held the horn valve down continuously in an effort ìto blow her

down,î11 but the bus did not stop. The engineer stated that when the bus continued to move

toward the crossing, he placed the train in emergency braking using the automatic brake

valve. According to the conductor, who was on the left side of the train and saw the bus

before it crossed the tracks, the driver was looking straight ahead when she crossed the

tracks. When the bus was on the crossing, the engineer said the driver turned to look at the

train, just prior to collision. Both the conductor and engineer stated that before the

collision they noticed that the door of the bus was closed.

6 The dispatcher held the train at the siding to allow several northbound trains to pass.

7 Reported by the conductor and confirmed by the locomotive event recorder.

8 A ìmedium clearî signal indication permits a train to proceed at 30 mph, per CSXT operating rule

283.

9 A ìclearî signal indication permits a train to proceed at the maximum timetable speed, per CSXT

operating rule 281, which was 60 mph on this track.

10 Wayside detectors monitor passing trains for mechanical defects, such as dragging equipment, and

typically record train speed, time, axle count, ambient temperature, and other data.

11 Alert the busdriver.
Factual Information 5 Highway Accident Report

Collision

The train struck the school bus on the passenger side between the axles. During the

accident sequence, the bus body and its chassis struck the crossbucks and separated, and

the chassis came to rest 64 feet west-southwest of the center of the grade crossing; the

chassis was facing east. The front of the bus body, including the section to which the

driverís seat was attached, separated from the rest of the body and remained with the

chassis, which rolled on its passenger side and later rolled back upright. The body, pushed

down the tracks by the locomotive before pivoting off and rotating clockwise about 180

degrees, came to rest 192 feet west-southwest of the center of the crossing (see figure 3).

That part of the bus body immediately behind the separation point was flush with the train

body (see figure 4). Broken branches and scrape marks were found on rows of trees

approximately 112 feet and 157 feet from the grade crossing. The train did not derail, and

the locomotive came to rest about 1,990 feet from the crossing. During the accident

sequence, the bus body scraped several branches and struck a tree near the area where the

bus came to rest. Bus tire rub marks were found on the inside of the rail.

Figure 3. Postaccident scene diagram.

10 MPH

B

0 15' 30' 60'

Liberty Church Road

School bus body

at-rest position

School bus chassis

at-rest position

Post-collision path

of school bus body

Bus

driver

Post-collision evidence

from school bus

N

Passenger

1A

Passenger

1F Passenger

12A

Conasauga, Tennessee

Source: National Transportation Safety Board

Trees and shrubs

LIMITED

SIGHT

DISTANCE
Factual Information 6 Highway Accident Report

Injuries

The following table is based on the International Civil Aviation Organizationís

injury criteria,12 which the National Transportation Safety Board uses in accident reports

for all transportation modes.

Table 1. Injuries.

Figure 4. Accident bus.

12 Title 49 Code of Federal Regulations 830.2 defines a fatal injury as any injury that results in death

within 30 days of the accident. It defines a serious injury as one that requires hospitalization for more than

48 hours, commencing within 7 days from the date the injury was received; results in a fracture of any bone

(except simple fractures of the fingers, toes, or nose); causes severe hemorrhages, nerve, muscle, or tendon

damage; involves any internal organ; or involves second or third degree burns or any burns affecting more

than 5 percent of the body surface.

Injuries Driver Train crew Bus passengers Total

Fatal 0 0 3 3

Serious 0 0 3 3

Minor 1 0 1 2

None 0 2 0 2

Total 1 2 7 10
Factual Information 7 Highway Accident Report

Medical and Pathological Information

The busdriver was wearing a lap/shoulder belt, which broke during the accident

sequence, resulting in her ejection from the bus. Her minor injuries included a fractured

nose, contusions, abrasions, and lacerations. The passenger seated in the second row (seat

2A) (see figure 5) also sustained minor injuries, including blunt abdominal trauma with

abrasions and contusions. This passenger was reportedly wearing a lap belt.

One of the ejected passengers (seat 1A), who was ejected through the front

opening of the bus body after its separation from the chassis and was severely injured,

sustained a closed head injury, multiple scalp lacerations, left arm and leg fractures, and

wedging of several thoracic vertebrae. The seriously injured passenger who was ejected

and found pinned under the front passenger-side corner of the bus (seat 1F) sustained a

closed head injury, liver contusions, multiple facial lacerations, abrasions, and contusions.

The seriously injured passenger who was seated across from the area of intrusion (seat

6A) sustained a closed head injury with intraventricular hemorrhage, a right frontal lobe

contusion, right first rib fracture, and multiple facial lacerations.

Figure 5. Seating chart.

M - 09 : F

DRIVER

F - 34 : M

F - 09 : F

ICAO INJURY LEGEND

SAMPLE

F = FEMALE M = MALE # = AGE

*International Civil Aviation Organization AOI = Area of Impact

CONASAUGA, TENNESSEE

INJURY LEVEL

AGE

GENDER

*

F - 14 : M

ABC DEF

1

2

3

4

5

6

7

8

9

10

11

12

F - 08 : M

F - 05 : S

M - 08 : S

F - 07 : F

M - 06 : S

Source: NTSB

N

M

S

F

=

=

=

=

None

Minor

Serious

Fatal

AOI

(EJECTED)

(EJECTED) (EJECTED)

(EJECTED)
Factual Information 8 Highway Accident Report

Two fatally injured passengers (seats 6F and 8F) were seated in the area of impact,

and each sustained a linear skull fracture, left subdural hemorrhage, cerebral cortical

contusions, lacerations, and contusions. In addition, the passenger in seat 6F received a

posterior right rib fracture with right hemothorax, hemoperitoneum, and spleen laceration.

The passenger in seat 8F also received a severe facial fracture, subarachnoid hemorrhage,

and left femur fracture. The fatally injured passenger seated in the last row (seat 12A),

who was ejected, sustained a transected aorta; lacerations of the right atrium, liver, and

spleen; bilateral hemothorax; left lateral pericardial sac hemopericardium; fractures to the

left ribs, right clavicle, and right tibia-fibula; and multiple contusions, lacerations, and

abrasions. This passenger also had abrasions and linear contusions from the chest midline

extending laterally to the right and left of the chest midline.

Toxicological Tests

The Federal Motor Carrier Safety Regulation at 49 Code of Federal Regulations

(CFR) 382.303 requires that in accidents such as the Conasauga collision, postaccident

alcohol and drug testing be performed on the busdriver; 49 CFR 40.21 specifies that the

drug testing be done for marijuana, cocaine, opiates, amphetamines, and phencyclidine.

Erlanger Medical Center in Chattanooga, Tennessee, conducted the postaccident

toxicological testing on the accident driver, and the results were negative. According to

the Federal Motor Carrier Safety Regulations, the test was invalid because it did not test

for phencyclidine.

Safety Board investigators sent samples of the busdriverís blood and urine to the

Civil Aerospace Medical Institute for further testing. Results revealed the presence of

pseudoephedrine and ephedrine in the blood and urine. Phenylpropanolamine was present

in the urine but not in the blood. All of these substances are common ingredients in overthe-counter cold medications and weight-loss products. No evidence of alcohol or illicit

drugs was found in either sample.

Neither Federal regulations nor CSXT policy require toxicological testing for a

train crew after a grade crossing collision. The engineer and the conductor volunteered to

be tested, and the results were negative for drugs and alcohol for both employees.

Survival Aspects

Emergency Response

Dispatch Center. When a driver who had turned onto Liberty Church Road from

Route 411 came upon the accident scene, she placed a 911 call to the Murray County 911

Center from her cellular telephone at 6:41 a.m. She stated that a school bus and train had

collided at a railroad crossing, but she did not know the precise location because there was

no signage (this was not her usual route). She believed the accident occurred 1/2 mile
Factual Information 9 Highway Accident Report

north of St. Claireís gas station. At 6:45 a.m. she called the 911 center again, this time

from St. Claireís gas station on Route 411, where she had learned that the road at the

accident scene was Liberty Church Road. This information was then relayed to the fire,

rescue, and emergency medical services (EMS) units, which had been dispatched at 6:44

a.m., and were already en route to the scene. The Polk County Sheriffís Department did

not receive any calls reporting the accident. At 6:56 a.m. the Polk County Sheriffís

Department received a call from the Murray County 911 Center requesting two EMS

ambulances to assist in the response.

CSXT. Earlier, while the train was coming to a stop, the conductor had called

ìTone 9,î13 and according to train dispatcher radio transcripts, the dispatcher answered the

emergency call from train S-213-25 at 6:43 a.m. After confirming the location and identity

of the train, the dispatcher called the CSXT Police Communications Center at 6:44 a.m.

and informed the police communications specialist of the emergency. At 6:47 a.m., the

Murray County Sheriffís Office received a phone call from the CSXT Police

Communications Center in Jacksonville, Florida, reporting the nature and location of the

accident. About 2 minutes later, the Murray County Sheriffís Office 911 operator called

the CSXT Police Communications Center and confirmed information about the location

of the accident.

On-Scene Activities. At 6:50 a.m. the first fire command officer and engine

arrived at the scene and requested additional assistance, as well as a medical evacuation

helicopter. The first helicopter departed Erlanger Medical Center in Chattanooga,

Tennessee, at 6:59 a.m. and arrived at the Rostex airstrip landing zone established near the

accident scene at 7:17 a.m. Another helicopter departed Knoxville, Tennessee, at 7:08 a.m.

and arrived at the landing zone at 8:03 a.m. By 7:06 a.m., all passengers had been

extricated from the vehicle. At 7:17 a.m., the 911 center was advised that no additional

EMS units were needed.

In all, 17 firefighters from Murray County responded, and 5 ambulances were sent

to the scene (3 from Murray County and 2 from Polk County). The ambulances

transported four passengers to the Rostex airstrip to be airlifted to Erlanger Medical

Center. Two passengers were taken by ground transportation to Murray County Hospital

and stabilized until they could be airlifted to Erlanger Medical Center. A formal disaster

plan was not initiated. The Murray County Fire Services Director reported to investigators

that no problems occurred during the response.

Survivability

The school bus driver, who sustained minor injuries, was wearing the three-point

lap/shoulder belt available at the driverís seat. The belt webbing failed during the accident

sequence and the driver was ejected. The passenger14 seated in the second row on the

driver side was wearing the available lap belt and sustained minor injuries.

13 ìTone 9î is a radio tone specified as the method for contacting the train dispatcher in an emergency.

14 This passenger was 4 feet 5 inches tall and weighed 117 pounds.
Factual Information 10 Highway Accident Report

Two of the fatally injured passengers were seated in the impact area. The third

fatally injured passenger was seated in the last row of the school bus and was ejected. Two

of the seriously injured passengers were seated in the first row of the bus and were not

using the available lap belts. Both of these passengers were ejected and one was found

under the front right corner of the bus body. The third seriously injured passenger was

seated on the driver side, across from the impact area.

Personnel Information

School Bus Driver

The Murray County School District hired the 34-year-old school bus driver as a

full-time substitute busdriver15 on May 11, 1999. She became a full-time busdriver at the

beginning of the 1999-2000 school year. Between September 16, 1997, and September 16,

1998, she was a school bus driver at Olympic Truck Lease, which had a contract with the

Dalton City, Georgia, schools for pupil transportation. The busdriver had a valid Georgia

commercial driverís license (CDL) with a passenger endorsement, which expired on May

3, 2001. A corrective lens restriction was noted on the license, but it could not be

determined whether the busdriver was wearing glasses or contact lenses at the time of the

accident. Her driving record included a single conviction for speeding (61 mph in a 45

mph zone) while driving her personal vehicle on September 21, 1991.

Pupil transportation officials with the Dalton City Public Schools stated that the

busdriver attended a 4-hour training class on January 20, 1998, which covered operational

and driving procedures, including procedures at railroad/highway grade crossings.

According to the officials, the busdriver was verbally reprimanded during the session for

talking during class, and her response to the reprimand was that she did not understand

why she had to attend the training because she already knew the material.

All drivers in Murray County are required to attend an 8-hour mandatory training

session annually with a State Department of Education consultant and a State patrol

officer for recertification as school bus drivers. The training includes information on the

proper procedures to follow at grade crossings. The accident busdriver had received her

training and annual recertification on August 12, 1999. The principal stated that he had not

received any complaints about the busdriver and noted that teachers, parents, and students

liked her. Except during summer vacation, the driver had been driving the same route

since May 1999.

The busdriver tested negative for drugs and alcohol in a preemployment drug

screen on May 9, 1999; no random drug tests had been performed on the driver since that

time. She received her annual physical examination on July 14, 1999, and was found

medically qualified to drive a school bus. Medical records obtained from the driverís

15 Full-time substitute busdrivers drive every day but not necessarily the same route.
Factual Information 11 Highway Accident Report

personal physician revealed that she was diagnosed with diabetes mellitus type II16 on

November 5, 1999, but insulin was not required for treatment. She had episodes of high

blood pressure in October and December 1999; no repeated levels of high blood pressure

were indicated thereafter and her blood pressure was normal in January, February, and

March 2000. Neither of these conditions disqualified her from holding a CDL.

The busdriver took her bus home nightly because of the convenient location of her

residence to the bus route. She usually departed her home in Chatsworth, Georgia, about

6:10 a.m.; drove to the Liberty Church Road area and picked up the first passengers about

6:35 a.m.; and arrived at Northwest Elementary School in Chatsworth, Georgia, between

7:30 and 7:40 a.m. She departed Northwest Elementary School about 2:00 p.m. on her

afternoon route.

Train Crew

The conductor and engineer had been called on duty at Etowah, Tennessee, at 2:20

a.m. on the day of the accident. The engineer had been off duty for the required 10-hour

period, and the conductor had been off longer than 10 hours. Both men indicated that they

had slept well the evening before the accident. The engineer and conductor reported to the

yard office, received documentation, and departed by taxi at 3:45 a.m. to the Ocoee siding,

where the train was located, 19 miles south of Etowah.

The 50-year-old engineer had been a railroad employee on the Etowah subdivision

since 1972 and became a conductor in 1975. He entered the CSXT engineer training

program in 1995 and was promoted to engineer in 1996. CSXT employee records listed

the engineer as medically qualified without restrictions. The engineer last took the CSXT

operating rules class17 on January 6, 2000, and had last passed an engineer certification

class18 on December 31, 1998.

The 51-year-old conductor had been a railroad employee since 1977 and was

promoted to conductor in 1984. The conductor said he had worked most of his career on

the Etowah subdivision and that he was familiar with the territory. CSXT employee

records listed the conductor as medically qualified without restrictions. The conductor had

last attended a CSXT operating rules class on January 23, 2000.

School Bus and Wreckage Information

School Bus

The 1999 Blue Bird Corporation 72-passenger school bus had an International

Truck and Engine Corporation chassis, diesel engine, power steering, automatic

16 Generally, type II diabetes can be controlled through oral medication, weight loss, and diet.

17 Periodic rules instruction is required by 49 CFR Part 217.11.

18 Title 49 CFR Part 240.
Factual Information 12 Highway Accident Report

transmission, and antilock brakes. The electronic control module was not capable of

recording vehicle operational data but did provide system fault and diagnostic

information. The data indicated no fault codes or abnormalities upon inspection after the

accident. The odometer reading was 24,219 miles. The school bus was approximately 452

inches long and had a gross vehicle weight rating of 26,384 pounds.

The school bus had 12 rows of three-passenger bench seats on both sides of the bus

and modesty panels in front of the first row. The first two rows were equipped with lap

belts19 in all designated seating positions. The bus was equipped with seven emergency

exits: two roof vent hatches, four side window exits (two on each side), and one rear

emergency door.

The driverís seat was equipped with a lap/shoulder belt. The latch plate receiver

was mounted to the seatframe on the passenger side and tethered to floor anchorages

below the driverís seat. The continuous loop strap with free-sliding latch plate was seatmounted and floor-tethered on the left side of the driverís seat in the same manner as the

receiver. The continuous loop passed through the D-ring and terminated at an emergency

locking retractor, which was mounted to the bus body sidewall panel at the roofline to the

rear and above the driverís left shoulder position, 16 inches behind the seat. The driverís

seat and lap belt anchorages were mounted to the school bus body.

The bus body was secured to the chassis using bolts and body-to-chassis mounting

clips, in accordance with design specifications of the National School Transportation

Specifications and Procedures20 manual and current industry practices. The front section

of the bus body (below the driverís seat) was attached to the chassis with tie down

brackets secured by four grade 8 bolts (higher grade than the rest of the bolts).21 The body

cowl panels were secured to the chassis by 25 bolts and locknuts.

The school bus was equipped with an AM/FM cassette radio with an integrated

public address system and four overhead speakers. One speaker was located above and

just to the rear of the driverís seat, and the remaining speakers were in roof panels above

rows 4, 7, and 11. After the accident, investigators found the toggle switch for the speakers

in the ìINTî position, indicating that all four speakers were active. The two interior roof

panels located above the driver were lined with sound attenuation materials.

The bus was equipped with a ìSilent Witnessî in-vehicle video camera, mounted

midline approximately 71 inches above the floor at the front of the bus. The video recorder

was on at the time of the accident (see Bus Video Recorder section).

The bus was equipped with two 291-inch-long open-style overhead storage racks

mounted above the windows on both sides of the body (see figure 6). Angled padding

19 Lap-only belt.

20 National School Transportation Specifications and Procedures, 2000 Revised Edition (Warrensburg,

MO : Missouri Safety Center, 2000).

21 Society of Automotive Engineers standard; grade 8 bolts have the highest tensile strength of

commercially available bolts.
Factual Information 13 Highway Accident Report

protected the aisle side of the rack. Five metal bars formed the rack along the length of the

bus. According to Blue Bird Corporation, the racks were 61.13 inches above the floor.

They were located outside the head protection zone, as defined by Federal Motor Vehicle

Safety Standard (FMVSS) 222 (49 CFR 571.222.5.3.1.1),22 and thus were not required to

comply with head protection requirements.

Maintenance records indicated no recurring maintenance problems or recent

repairs to the vehicle. Safety Board investigators conducted a postaccident inspection of

the vehicle and found no mechanical defects.

School Bus Damage

The school bus body separated from the chassis at the engine compartment

cowling23 and the forward roof panel above the windshield. The driverís seat, windshield,

engine cowling, entrance stairwell, firewall, and dash controls remained attached to the

part of the bus body still attached to the chassis. The chassisí main frame rails were

deformed rightward from the drive axle rearward; maximum deformation was 44.63

inches. The drive axle was displaced leftward 7.8 inches. Frame rail cross members and

rear bumper supports were also damaged (see figure 7).

22 The upper limit of the head protection zone is 40 inches above the seating reference point. This is

about 58.62 inches above the floor in this bus, according to Blue Bird Corporation.

Figure 6. Roof rack.

23 Metal cover for the engine.
Factual Information 14 Highway Accident Report

Damage to the bus body was extensive in the immediate area of impact; maximum

intrusion was 44.85 inches (figure 8). In addition, induced damage, in the form of bowing

of the body structure, was substantial. The right rear corner of the bus was skewed

rightward 42.67 inches and forward 40.85 inches (see figures 9 and 10). 

Figure 7. Bus chassis.

Figure 8. Bus body deformation.

36.44" 42.08" 44.85" 40.56" 40.85"

42.67"

45.47"

8.82"

13.70"
Factual Information 15 Highway Accident Report

Postaccident inspection showed the driverís seat tilted toward the passenger side of

the bus (see figure 11). The left lap belt segment extended from the edge of the seat

cushion to the floor of the bus and was taut, while the right lap belt segment extended from

the edge of the seat cushion to the floor of the bus and was slack. The driverís seat and the

floor anchorages remained attached to the body flooring, which was in turn attached to the

chassis. The shoulder belt passed through the D-ring, and the D-ring and the emergency

retractor were located on the sidewall of the bus body (see figure 12). The shoulder belt

webbing was torn, some of it remained with the driverís seat, and the rest remained with

the sidewall-mounted retractor. 

Figure 9. School bus exterior body damage.

Figure 10. School bus interior body damage.
Factual Information 16 Highway Accident Report

Figure 11. Driverís seat.

Figure 12. Portion of driverís shoulder belt 

attached to bus body.
Factual Information 17 Highway Accident Report

Except in the area of maximum intrusion, the seat cushions remained fixed to the

seatframes. Damage was noted to the seatframe attachments in the area of maximum

intrusion; the seatframes were not dislocated from the floor. The modesty panels remained

intact.

Severe damage to the roof rack was noted on the passenger side of the bus.

Damage to the sidewall and roof of the bus caused the rack to rotate approximately 90

degrees, with the opening into the rack facing the top of the roof. Although twisted and

bent after the accident, the racks remained securely attached to the bus body. The rack on

the driver side of the bus was almost completely intact, except near seats 6 and 7, where

induced deformation was present. This deformation was near the area of maximum

intrusion.

Train and Wreckage Information

Train

Train S-213-25 consisted of 1 locomotive and 33 loaded auto-rack cars. The train

was 3,173 feet long and had a gross weight of 2,465 tons. The locomotive was a six-axle

General Electric C40-8 powered by a 16-cylinder engine rated at 4,000 horsepower. The

locomotive weighed 395,000 pounds. The locomotive had received its required annual

brake servicing on March 26, 2000.

Locomotive warning devices included an air-operated bell, a five-chime Nathan

ìAirchimeî horn mounted on the top of the locomotive body, a standard two-bulb

headlight, and two ditch lights on the leading edge of the front walkway. When the horn

was sounded, the ditch lights oscillated in an alternating on-off pattern. Audiometer

testing revealed that the horn exceeded the Federal requirement in 49 CFR 229.129 of 96

decibels when measured 100 feet ahead of the locomotive.

Train Damage

The steps on the front left side of the locomotive, CSX 7580, were displaced

rearward about 4 inches. There was yellow paint transfer on the snowplow and coupler.

Both ditch lights were broken and the light brackets were bent back about 2 inches. The

hand railings on the front walkway were bent back toward the body. CSXT estimated

damage to the locomotive at $1,500. The first car behind the locomotive was an 89-foot

flatcar equipped with a trilevel auto rack. The side panel of this car was damaged; CSXT

estimated repair costs at $200. The track was not damaged.
Factual Information 18 Highway Accident Report

Crossing Information

Highway

Liberty Church Road is an 18-foot wide, two-lane road without a centerline that

winds about 1.8 miles in a ìUî shape from Route 411 in Georgia back to Route 411 in

Tennessee. No street name signs identify it as Liberty Church Road, nor do street signs

mark any other roads in Polk County, Tennessee. At the time of the accident, two advisory

signs were present as vehicles approached the crossing. One was a round railroad advance

warning sign24 314 feet east of the nearest rail, and the other was a diamond-shaped

warning sign25 200 feet east of the nearest rail that stated ìLIMITED SIGHT

DISTANCE,î below which was a supplemental advisory speed sign26 that stated ì10

MPH.î At the crossing was a railroad crossing sign (crossbucks) on the right side of the

roadway (see figure 13). According to the Polk County Superintendent of Highways, an

engineering study regarding the selection and placement of the advance warning signs and

placards for the Liberty Church Road grade crossing had not been conducted.

24 W10-1.

25 W11.

26 W13-1.

Figure 13. Driverís view of Liberty Church Road approaching the crossing.
Factual Information 19 Highway Accident Report

The road approaching the tracks from the west was 18.1 feet wide and narrowed to

15 feet wide just before the crossing. At the center of the crossing, the road was 14.5 feet

wide. It had a downhill grade of 12.9 percent prior to and 10 percent at the railroad

advance warning sign. Adjacent to the ìlimited sight distanceî sign the grade was 5

percent. Just before the crossing, the roadway had a 2-percent downgrade that transitioned

to a flat surface across the rails. The roadway surface was asphalt on the approach and

between the rails; rubber transition treatments were on each side of the rails. The roadway

had been resurfaced in fall 1999.

Records showed no previous accidents at the grade crossing. After this accident

and the subsequent upgrade of the crossing to active devices consisting of lights and gates,

all signs were removed. New round railroad warning signs (W10-1) were installed in

advance of the crossing, and two signs (W10-3s, one in each direction) were placed on

Route 411, indicating a grade crossing on Liberty Church Road.

Railroad

The accident occurred at milepost 362.82 on the north-south track of the Etowah

subdivision at crossing 347 942 N. A toll-free number is posted on the crossbuck posts at

the crossing for reporting stalled vehicles or an emergency to CSXT. Daily track

inspection reports for the 6 months before the collision indicated no track problems near

the grade crossing.

Operations Information

School Bus Operations

The Murray County School District owned and operated the accident bus. The

school district comprises five elementary schools, two middle schools, one high school,

and one alternative school in a 344-square mile area. In the 1999-2000 school year, the

student population was 6,559, of whom 3,930 were transported daily on school buses. The

school district had a fleet of 74 buses and employed 54 full-time busdrivers and 7

substitute drivers. Vehicles were maintained by a shop foreman, three full-time mechanics

and one part-time mechanic, who was also a busdriver.

Training. Murray County provides annual mandatory training, as required by the

State, to its busdrivers for recertification. During this training, information on

railroad/highway grade crossings is provided. On February 3, 2000, Operation Lifesaver27

presented a training class in Murray County attended by eight busdrivers. School officials

reported that because of a lack of funding, busdrivers could not be paid to attend and were

not required to be present. The accident busdriver did not attend the session. Since this

27 Operation Lifesaver is a nonprofit nationwide effort to educate the public and increase public

awareness of the hazards at railroad-highway grade crossings and to develop proper driver behavior patterns

at grade crossings. Operation Lifesaver participants include State and local officials, civic groups, safety

organizations, transportation industry groups, labor groups, public information media, and private citizens.
Factual Information 20 Highway Accident Report

accident, Murray County School District has been working with Operation Lifesaver to

provide mandatory, in-depth driver training for railroad/highway grade crossings. Drivers

are now paid to attend this training.

Routing. According to Murray County School District officials, the school district

has 18 railroad crossings, 15 of which were crossed by school buses at the time of the

accident. These figures do not include the Liberty Church Road crossing, which is not in

Murray County. School bus routes were established several years ago and change

periodically depending on population and location of the students. The school districtís

transportation director stated that grade crossings are considered in routing and that some

routes have been changed to utilize active rather than passive crossings. In rural areas,

roadways sometimes only enter and exit an area one way and must cross the tracks.

According to the transportation director, the Liberty Church Road school bus route crosses

the railroad tracks because the intersection of Liberty Church Road and Route 411 in

Georgia is such that, if the bus turned around and exited in Georgia (eliminating the need

to cross the tracks), the bus would have to go into the opposing lane of traffic to turn onto

Route 411. The accident vehicle was the only Murray County school bus that traversed the

Liberty Church Road crossing. A Polk County school bus also crossed the tracks.

Safety Board investigators reviewed several Murray County school district route

maps during the investigation and noted that none documented any road hazards.

Following this accident, the school district revised some routes, so that currently, only one

route crosses a passive crossing because that neighborhood has no other way out. The

intersection of Liberty Church Road and Route 411 was redesigned so that a school bus

can now turn around on Liberty Church Road and enter Route 411 without encroaching on

the opposing lane.

Busdriver Procedures. Title 40-6-142 of Georgia State law, which governs the

procedures of school bus drivers at railroad/highway grade crossings, states:

The driver of any motor vehicle carrying passengers for hire or of any school bus,

whether carrying school children or empty before crossing any railroad tracks

shall stop such vehicle within 50 feet but not less than 15 feet from the nearest

rail, look and listen for a train and not proceed until safe to do so.

Tennessee law is the same, except that drivers are not required to stop if there are

no children on the bus.

In the districtís Bus Drivers Manual: Procedures and Rules, under the section

entitled ìState Law and Policy,î the Murray County schools list seven steps to be followed

at railroad crossings:28

a. Always come to a complete stop.

b. Stop not closer than 15 feet, but not farther than 50 feet, from the nearest rail.

28 These steps are adapted from the National School Transportation Specifications and Procedures.
Factual Information 21 Highway Accident Report

c. Open service door and left front window. Cut off radio, fans and heaters.

d. Look both ways ñ Listen!!

e. A school bus driver does not activate warning lights while approaching or

stopped for a railroad crossing.

f. When tracks are clear and safe, proceed forward. Do not shift gears while

crossing.

g. Close door and continue route.

One question on the Georgia CDL test, which a school bus driver must pass,

addressed the effect of minimum and maximum stopping distances to the nearest rail on a

driverís ability to see down the track.

Railroad

Each day, 30 to 35 trains travel on the Etowah subdivision, which runs from

Etowah, Tennessee, to Junta, Georgia, a distance of 87.6 miles. No revenue passenger

trains operate in the subdivision. According to CSXT, the Etowah subdivision is often

congested due to bottlenecks in the Atlanta area and scheduled track maintenance. Rail

freight volume for the subdivision increased from 48.6 million annual gross tons in 1998

to almost 49.9 million tons in 1999. The subdivision is a single-track main line with

numerous passing sidings. In the area in which the accident occurred, CSXT Atlanta

division timetable No. 1, dated October 1, 1999, indicates that the maximum track speed is

60 mph for intermodal trains and for trains comprising solid blocks of auto racks, such as

the accident train; all other trains are limited to 50 mph.

Train times and directions of travel do not follow a fixed schedule; wayside signal

indicators govern train movement. Before the accident, the most recent train to pass the

Liberty Church Road crossing was headed northbound about 6:10 a.m. Signal records

indicate that 26 trains had passed over the accident site between 6:00 a.m. and 7:00 a.m. in

the 25 days preceding the accident.

Management Information

Murray County Oversight

Under ìPerformance Appraisal/Evaluation,î the Murray County School Districtís

Bus Drivers Manual: Procedures and Rules states: ìEach employee is appraised on

common factors according to the contents of the job description. An employee is rated on

unique factors if contained in the job description.î Neither the accident busdriverís

personnel file nor those of other busdrivers contained documentation indicating that their

performance behind the wheel had been evaluated or rated.
Factual Information 22 Highway Accident Report

State Oversight

The Georgia Department of Educationís (DOEís) Office of Learning and

Achievement, Student Transportation Services, includes five full-time consultants, located

throughout the State, who assist the school districts. All consultants are State-certified

school transportation trainers who have advanced degrees in education. The consultants,

coordinating through the DOE, conduct the annual recertification training for school bus

drivers. According to the director of pupil transportation, the agencyís mission is to

provide service rather than serve a regulatory function; its area of expertise is pupil

transportation systems. The DOE allocates funds for pupil transportation operations; about

40 percent of the funds cover the purchase of new buses.

Georgiaís director of pupil transportation is a member of the National Association

of State Directors of Pupil Transportation Services (NASDPTS). Local school district

transportation directors in Georgia primarily receive information provided by the

NASDPTS through mandatory annual in-service training.

According to the State pupil transportation directorís office, busdriver evaluation

programs are not mandatory and depend upon the size of the school district; smaller

school districts often lack the manpower to conduct them.

School Transportation Standards

National. The National Highway Traffic Safety Administration (NHTSA) has

published National Highway Safety Program Guideline No. 17, which establishes

minimum recommendations for pupil transportation safety; it includes recommendations

on the identification, operation, and maintenance of buses used to transport students.

Georgia is among the States that have adopted guideline No. 17.

Section C-2b of the guideline, which sets forth recommended practices for the

routing of school buses, states:

Each State should develop plans for minimizing highway use hazards to school

bus and school-chartered bus passengers, other highway users, pedestrians,

bicycle riders, and property. They should include, but not be limited to: (1)

Careful planning and annual review of routes for safety hazards; (2) Planning

routes to ensure maximum use of school buses and school-chartered buses, and to

ensure that passengers are not standing while these vehicles are in operation.

Association. The National Conference on School Transportation (NCST) takes

place every 5 years for the purpose of developing the publication National School

Transportation Specifications and Procedures. The May 2000 conference attendees

included NASDPTS members from 48 States, as well as industry representatives.29 They

met to address and make recommendations concerning issues that had arisen since the

previous conference in 1995.

29 Hawaii and North Dakota were not represented.
Factual Information 23 Highway Accident Report

The resulting document was the 2000 National School Transportation

Specifications and Procedures published by the NASDPTS. The publication contains

guidelines, not requirements, and includes recommendations on public address systems in

school buses. It states that buses may be equipped with interior and exterior speakers, but

interior speakers should not be installed within 4 feet of the driverís seatback in its

rearmost upright position. No States opposed this specification. Georgia adopted the

guidelines for school bus construction contained in the 2000 National School

Transportation Specifications and Procedures but has not provided guidance on radio

speaker placement and operation to local school districts, which have the option of

developing specifications on this issue.

The NASDPTS, through a grant from NHTSA,30 recently developed a document

for the ìIdentification and Evaluation of School Bus Route and Hazard Marking

Systems,î which was incorporated in the 2000 National School Transportation

Specifications and Procedures. NHTSA made the grant as a result of the Safety Boardís

investigation of the 1995 Fox River Grove, Illinois, school bus accident31 and resulting

recommendations32 to the NASDPTS to:

H-96-52

Encourage your members to develop and implement a program for the

identification of school bus route hazards and to routinely monitor and evaluate all

regular and substitute school busdrivers.

H-96-53

Advise your members to consider railroad/highway grade crossing accident

histories or unusual roadway characteristics when establishing school bus routes.

The purpose of the grant was to research the issue of school bus route hazards and

marking systems, develop guidelines to identify the hazards, suggest ways to inform

school bus drivers of the hazards and how to deal with the hazards, and propose methods

to disseminate information to the community. Among the hazards identified were

railroad/highway grade crossings.

The 2000 National School Transportation Specifications and Procedures also

recommends a regular review of busdrivers for compliance with regulations and of bus

routes for accuracy and the presence of hazardous road conditions. At the most recent

30 NHTSA grant DTNH22-97-G-05155.

31 National Transportation Safety Board, Collision of Northeast Illinois Regional Commuter Railroad

Corporation (METRA) Train and Transportation Joint Agreement School District 47/155 School Bus at

Railroad/Highway Grade Crossing in Fox River Grove, Illinois, on October 25, 1995, Highway/Railroad

Accident Report NTSB/HAR-96/02 (Washington, DC: NTSB, 1996).

32 Safety Recommendations H-96-52 and -53 were classified ìClosedóAcceptable Actionî

(November 11, 1997) because the NASDPTS had provided the information requested by the Safety Board to

its members.
Factual Information 24 Highway Accident Report

NCST to update the practices, the committee recommended mandatory reviews but did

not specify the intervals.

Meteorological Information

At Lovell Field Airport in Chattanooga, Tennessee, approximately 30 miles from

the accident site, between 6:00 a.m. and 7:00 a.m. on March 28, 2000, the weather was

clear with light winds out of the south-southeast. The temperature was 46 degrees, dew

point was 39 degrees, and sunrise was at 6:33 a.m. The bus was traveling west and the

train, south; therefore, the sun did not obstruct the driverís view.

Tests and Research

Lap and Lap/Shoulder Belts and Seat Coverings

The driverís lap/shoulder belt webbing was severed near where it passed through

the free-sliding latch plate, which remained secured in the latch plate receiver on the

chassis. Loading marks33 were noted on the latch plate of the lap/shoulder belt and were

visible on the D-ring. Striations in the plastic cover where the webbing passed through the

latch were present along the length of the plastic.

The center lap belt34 in row two on the driver side of the bus had visible

indentation marks on the latch side of the webbing. No other belts showed marks. This

location corresponds to the seating position of the passenger who reported she was

wearing her lap belt.

The seatback of row 11 on the passenger side had blue fiber scuff marks, most

likely transferred to the seat cover from the passengerís (12A) clothing. More pronounced

fiber transfer occurred over creases created by the folded-over seat cover material. The

curvature of the creases and the severity of heat damage indicate that at impact the

passengerís (12A) body was moving toward the right and upward.

Locomotive Event Recorder

The event recorder35 on the CSXT locomotive was downloaded after the accident

and the data were taken to Safety Board headquarters for examination. The data showed

that the locomotive was in maximum throttle position prior to the collision and that the

33 Marks indicating that a force was exerted on the belt when it was in use.

34 The latch plate of the center lap belt overlapped with the left lap belts and could be latched to the left

seat buckle without the passenger being out of position.

35 The event recorder records data related to speed, time, and distance and to systems such as the horn,

throttle, and bell at 1-second intervals. The times and distances stated here are estimates based on the 1-

second intervals recorded.
Factual Information 25 Highway Accident Report

speed immediately before brake application and collision was 51 mph. The locomotive

bell had been activated after passing the last crossing, about 1.8 miles before Liberty

Church Road. The locomotive passed the whistle post about 14 seconds before impact and

at least 7 seconds before the horn was sounded. The horn was sounded for 3 seconds

(about 952 feet from the crossing), released for 2 seconds, and then sounded for about 9

seconds before impact (beginning about 574 feet from the crossing). The locomotive was

placed in emergency braking less than 2 seconds (about 122 feet) before the crossing. The

train came to a stop 50 seconds after the emergency brake application (about 1,990 feet

beyond the crossing).

Bus Video Recorder

All Murray County School District buses are equipped with a video monitoring

system consisting of a videocassette recorder (VCR) and color video camera. The system

on the accident bus was a Silent Witness brand (model SW210). The camera was mounted

at the front and center of the bus and pointed down the length of the passenger

compartment. The driver and the first two rows of seats were not within the cameraís line

of sight. The cameraís field of view included the remaining seats and windows at the rear

and on the driver and passenger sides of the bus.

School district policy is that each bus have a separate videocassette for each day of

the week stored on the bus. Each morning the driver is to remove the previous dayís

videocassette from the VCR and insert the current dayís videocassette. Once a

videocassette is inserted, the VCR automatically begins recording about 6 seconds after

electric power is supplied (by turning on busís the ignition switch). When the bus is turned

off, the VCR stops recording. According to school district officials, the VCR and camera

are used to record passenger behavior and are reviewed only if problems are reported.

The VCR from the accident bus and the videocassette in it were recovered at the

accident scene. Police also removed 1 other intact videocassette, 14 videocassette reels

that had separated from their cassette housings during the accident sequence, and 7

segments of loose magnetic videotape. Safety Board personnel examined the

videocassette removed from the VCR, as well as the reassembled videocassettes (made

from the reels found on scene).

Investigators were able to identify passengers and landmarks on the videotapes,

confirming that most of the videotapes had been recorded on the accident bus route. Using

sound recordings, they were also able to identify the driver on the videotapes. Staff

determined that the bus had crossed the railroad tracks 12 times in the videotapes, and in

each instance the accident driver was driving. The bus did not stop before crossing the

railroad tracks on nine occasions, including the accident, eight of which were in the 2

weeks preceding the accident; stopped twice (both times when another vehicle was

present behind the bus); and in one instance too much glare was present to make a

determination. Safety Board personnel identified 11 crossings on the videotape as the one

on Liberty Church Road and were unable to identify the 12th crossing.
Factual Information 26 Highway Accident Report

The videotape on the day of the accident revealed that the bus did not stop, that the

radio was playing, and that the train horn was not audible on the video recording.

Vehicle Speed

Using landmarks identified on the video, Safety Board personnel were able to

determine the speed of the bus as it approached the grade crossing on the day of the

accident. The calculated speed, as the bus traveled downhill toward the crossing, was 25 to

30 mph. The bus slowed as it approached the crossing to a calculated speed of 15 mph at

the driveway about 71 feet before the grade crossing. On the videotape, the trainís light

can be seen moving across the side window bars immediately prior to impact, which

helped staff calculate the busís speed.

An exemplar bus was used to determine a likely speed for the accident bus as it

traveled over the crossing. A volunteer busdriver, who was instructed to drive at a constant

speed over the crossing, reported that he was most comfortable driving between 10 and 15

mph, which corresponds to the speed calculated from the video.

Audibility Tests

Audibility tests36 were conducted inside an exemplar bus to determine whether the

driver should have been able to hear the train horn when stopped at the crossing.37 A

baseline reading, established using a sound level meter located near the driverís head,

indicated an ambient sound level within the bus of 68.2 decibels38 with the engine idling,

radio off, and door closed. With the radio on,39 the sound level inside the bus increased to

the 71.5- to 72.4-decibel range. When traveling downhill on Liberty Church Road

approaching the crossing, the interior sound level was 73 to 74 decibels with the radio off

and 76.2 decibels with the radio on. When the train was stopped 1,268 feet from the

crossing (at which point the test busdriver first could see the train) and the bus was

stopped at 15 feet, with the radio on and door closed, the train horn was sounded and the

sound level increased to 77 decibels; the volunteer driver inside the bus said he could

barely hear the horn. With the radio on and the door open, the train horn was sounded and

the sound level inside the bus increased to 81 decibels, and the driver stated that the train

horn was discernible over the ambient noise of the bus. With the radio off and the door

open, the sound level from the horn increased to 98 decibels.

36 A Bruel and Kjaer precision sound level meter, type 2232, serial number 1129820, with a wind boot

was used. The sound level meter was calibrated using a Bruel and Kjaer sound level calibrator type 4230,

serial number 1140357.

37 In performing these tests, the Safety Board coordinated with CSXT to ensure that no trains were

approaching the crossing.

38 Decibel is the degree of loudness on a scale of 0 (least perceptible sound) to 130 (average pain level).

It is a logarithmic scale, that is, an increase of 3 decibels is equivalent to doubling the sound pressure.

39 The radio volume was set at the same approximate knob location that was found on the accident bus

during postaccident inspection.
Factual Information 27 Highway Accident Report

Auditory Warnings

Research has shown that detecting the presence of a sound will not lead to

appropriate action unless the sound is identified40 or has reached the alerting level.41 If a

sound is to be identified, the warning signal must be 3 to 8 decibels above the threshold of

detection;42 if a sound is to reach the alerting level, the warning signal must be

approximately 10 decibels above the ambient noise.43

Safety Board testing during the Fox River Grove accident investigation44 showed

that at 100 feet from impact, the train horn was only 3 to 5 decibels above the ambient

noise level within the school bus. Investigators also found that the crossing bell was not

audible above either the ambient noise level of the school bus or that of passing traffic.

Sight Distance

Safety Board investigators conducted visibility testing at the accident scene. When

the bus was stopped 15 feet from the nearest rail, the train crew would have been able to

observe the bus when the train was 1,349 feet from the crossing. The school bus driver

could see the train when it was 1,268 feet from the crossing.

Geometric Design of Highways and Streets, published by the American

Association of State Highway and Transportation Officials (AASHTO), states that sight

distance is a primary consideration at crossings without train-activated warning devices,

such as the accident crossing. AASHTO recommends that the required design sight

distance along the railroad track from a crossing, for a combination of highway and train

speeds, be based on a 65-foot truck crossing a single set of tracks at 90 degrees. Given a

train speed of 60 mph and a vehicle departing from a stop, AASHTO recommends that the

sight distance along the track from the crossing be 1,439 feet so that the truck can safely

cross the tracks if a train is not seen. Using the same methodology and incorporating the

accident bus length and acceleration, the school bus would have required approximately

960 feet of sight distance along the tracks when stopped 15 feet from the nearest rail to

safely cross the tracks from a stop.

According to CSXT officials, the railroad right of way at the Liberty Church Road

grade crossing is 100 feet wide, 50 feet on each side of the track centerline. The officials

stated that CSXT brush-clearing activities call for a sight distance quadrant to be clear of

brush at highway grade crossings. This quadrant at the accident site is 60 feet wideó30

feet on each side of the track centerlineóand extends for 200 feet on either side of the

roadway. Each year, CSXT sprays this 400- by 60-foot quadrant to a distance of 12 feet on

each side of the track for weed control. Every 3 years, the brush is cut 30 feet from the

40 David M. Lipscomb, ìAudibility and the Law,î Forensic Audiology.

41 The ìalerting levelî is the sound level at which a person is aware of a sound and recognizes the

source.

42 The ìthreshold of detectionî is the sound level at which a person is aware of a sound.

43 Skeiber, Mason, and Potter, ìEffectiveness of Audible Warning Devices on Emergency Vehicles,î

Sound and Vibration, 1978.

44 NTSB/HAR-96/02.
Factual Information 28 Highway Accident Report

centerline, which is the distance the brush-cutting machine can reach while positioned on

the track. The brush at Liberty Church Road had last been cut in July or August 1998. The

400- by 60-foot quadrant contained no obstructions at the time of the accident.

Accident Simulation

Using a human vehicle environment system developed by Engineering Dynamics

Corporation45 and Mathematical Dynamical Models (MADYMO),46 Safety Board staff

conducted vehicle dynamics and occupant kinematics simulations for this investigation.

Although a simulation does not replicate the actual accident, it is designed to evaluate

specific mechanical and biomechanical issues for similar types of accident scenarios.

Results of the vehicle dynamics simulation verified that the train was traveling

about 51 mph and the bus was traveling about 15 mph at impact. The resultant peak

accelerations experienced by the bus during the initial lateral impact between the train and

the bus were 30 Gs47 at the center of gravity, 39 Gs at the last row of seats, and 31 Gs at the

first row of seats. The peak angular acceleration at the center of gravity was approximately

2,500 deg/sec/sec. The angular accelerations were higher at the last row due to the school

busís clockwise rotation away from the impact point, the pivoting of the bus about the

front axle, and the distance of the last row of seats from the impact location. During the

initial lateral impact, the velocity of the train changed by 1 to 2 mph due to emergency

braking, while the lateral velocity of the bus increased to the velocity of the striking train.

Because the train was much larger and heavier than the school bus, the severity of the

collision was more extreme for the bus.

Other Information

School Bus Transportation Safety

According to NHTSA, approximately 450,000 school buses are used to transport

23.5 million students to and from school over 4.2 billion miles annually throughout the

United States.48 About 54 percent of the student population, kindergarten through 12th

grade, ride a school bus daily to and from school. Between 1989 and 1999, NHTSAís

statistics indicate that 96 crashes occurred in which at least one passenger of a school bus

45 Staff used the Engineering Dynamics Vehicle Simulation model to determine the speed and approach

direction of the bus and the Engineering Dynamics Corporation Simulation Model of Automobile Collisions

to examine the lateral impact between the train and the bus, as well as the movement of the train and the bus

body and chassis separately after collision.

46 For further information on MADYMO, see MADYMO Userís Manual 3D Version 5.3, TNO RoadVehicles Research Institute, November 1997. The MADYMO simulation for this investigation was

conducted in conjunction with NHTSA and Information Systems and Services, Inc., a NHTSA contractor.

47 Acceleration of gravity.

48 U.S. Department of Transportation, National Highway Traffic Safety Administration, Traffic Safety

Facts 1999: School Buses, DOT HS 809 095 (Washington, DC: NHTSA, 1999).
Factual Information 29 Highway Accident Report

died. Three of those crashes were railroad/highway grade crossing accidents involving

school buses and resulted in 11 fatalities.49

In Georgia, about 12,600 school buses are used to transport over one million

passengers annually.50 For the 1998-1999 school year, Georgia reported 790 school busrelated accidents. In those accidents, 12 busdrivers, 162 passengers, and 60 passengers of

other vehicles were injured.51 No fatal injuries to busdrivers or passengers were recorded;

one driver of another vehicle died as a result of fatal injuries. The last fatal accident in

Georgia that involved a school bus and train occurred on October 23, 1974; it resulted in 7

fatalities and 71 injuries.52

Reporting Near Misses at Grade Crossings

After the accident in Conasauga, another locomotive engineer reported to

investigators that 11 days earlier, he had seen a school bus cross the tracks at Liberty

Church Road without stopping. This engineer stated that on March 17, 2000, between 3:00

p.m. and 3:30 p.m., ìThe school bus never attempted to stop, just like there were no

railroad tracks there. It never slowed down.î The school bus passed over the crossing

about 500 feet ahead of the train. The engineer said he noticed the driver was a woman but

that he did not look for any numbers on the bus until after it was over the crossing and

going up the hill. He reported that he was unable to see any numbers on the back of the bus

and was more concerned about what he had to do for the upcoming crossing.

The engineer told investigators that he did not report the occurrence because he

could not see the numbers on the bus. He stated that if he had been able to properly

identify the bus, he would have reported the incident.

According to company officials, CSXT locomotives commonly contain a placard

that depicts a school bus stopped at a grade crossing while a train is approaching and

instructs crews to report near misses. CSXT operation rule 100-F instructs crews to report

the occurrence of a near miss, including the failure of school bus drivers to stop at

crossings or to observe reasonable precautions at crossings when trains are approaching.

The crew is to make such reports, detailing full information, to the CSXT Police

Communications Center. If mobile access is not available, the train dispatcher may relay

the information.

Railroad/Highway Grade Crossing Safety

The Safety Board investigated 60 accidents at passive grade crossings that

occurred between December 1995 and August 1996 and, based on analysis of the findings,

49 These crashes occurred in Miltona, Minnesota, on November 16, 1989; Fox River Grove, Illinois, on

October 25, 1995; and Buffalo, Montana on March 10, 1998.

50 <www.doe.klz.ga.us>.

51 Data provided by Georgia Department of Education, School Transportation Services.

52 Aragon, Georgia, NTSB/RHR-75/01.
Factual Information 30 Highway Accident Report

issued a study53 on safety at passive grade crossings. Driver error was cited as the primary

accident cause in 49 of the 60 cases. The study also noted that drivers at a passive grade

crossing are not provided warnings from train-activated devices; consequently, they must

rely on a system of grade crossing signs and pavement markings and on passive devices,

such as crossbucks, that are designed to warn drivers only of the presence of a crossing.

No element of this passive system changes to alert drivers to the presence of an oncoming

train.

Some conclusions reached by the safety study are:

Consolidation (the separation and closure) of passive crossings is the most

effective means to eliminate accidents between highway vehicles and trains. The

next most desirable method to improve safety at passive crossings is to equip

these crossings with active devices that warn the motorist of an oncoming train.

Installation and enforcement of stop signs at passive crossings would provide for

consistent information, instruction, and regulation to the motoring public and

would improve the safety of the Nationís passive grade crossings.

Stop Signs At Passive Grade Crossings. The 1998 Safety Board study54 made

19 recommendations to improve safety at passive grade crossings, including one to the

U.S. Department of Transportation (DOT) to:

H-98-28

Provide full funding within 3 years for the installation of stop and stop ahead signs

at passive grade crossings.

The DOT responded on December 23, 1998, that funding is provided through 23

United States Code 13055 and 13356 and that the DOT would inform the States of the

availability of such funding. The Safety Board replied on March 29, 2001, that it did not

believe this action alone would meet the intent of the recommendation because it did not

provide full funding. The Safety Board is awaiting further response from the DOT.

53 National Transportation Safety Board, Safety at Passive Grade Crossings, Volume 1: Analysis,

Safety Study NTSB/SS-98/02 (Washington, DC: NTSB, 1998).

54 NTSB/SS-98/02.

55 Railroad-Highway Crossings Program.

56 Surface Transportation Program.
Factual Information 31 Highway Accident Report

The 1998 safety study also made several recommendations to the States, including:

H-98-34

Install, within 2 years of receiving Federal funding, stop signs at all passive grade

crossings unless a traffic engineering analysis determines that installation of stop

signs would reduce the level of safety at a crossing. Crossings where conditions

are such that the installation of stop signs would reduce the level of safety should

be upgraded with active warning devices or should be eliminated.

Of the 11 passive crossings in Polk County and the 8 passive crossings in Murray

County that were examined by Safety Board investigators, only 3 in Murray County were

equipped with stop signs. No stop signs were installed at any crossings in Polk County.

In discussions with the Chairman of the Safety Board on October 25, 2000,

Tennessee officials indicated that they intended to install stop signs at all passive crossings

but were awaiting funding; consequently, in a January 5, 2001, letter, the Safety Board

classified Safety Recommendation H-98-34 ìOpenóAcceptable Responseî for

Tennessee. The Safety Board has not received a response to this recommendation from

Georgia, nor from 19 other States. Of the remaining States, the recommendation has been

classified ìOpenóAcceptable Responseî for 16 States, ìOpenóUnacceptable Responseî

for 7 States, ìClosedóUnacceptable Actionî for 4 States, and ìClosedóAcceptable

Actionî for 2 States (Idaho and Hawaii). The Safety Board closed the recommendation for

Idaho and Hawaii because Idaho already requires installation of stop signs at passive

grade crossings unless an engineering study dictates otherwise (the only State with this

requirement) and because Hawaii only has two passive grade crossings, for which stop

signs have already been installed.

The Manual on Uniform Traffic Control Devices, published by the Federal

Highway Administration (FHWA), establishes national standards for traffic control

devices and all States are required to be in substantial conformance with the manual.57

Concerning the use of stop signs at grade crossings, it states:

At the discretion of the responsible State or local highway authority, STOP (R1-1)

or YIELD (R1-2) signs may be used at highway-rail grade crossings that have two

or more trains per day and are without automatic traffic control devices.58

Installation of Active Warning Devices. According to the FRAís grade crossing

inventory, Tennessee has about 2,145 passive grade crossings. The State receives Federal

funds for the installation of active warning devices at railroad/highway grade crossings

and installs 35 to 45 such devices each year.59 Tennessee uses the Federal Railroad

Administrationís (FRAís) hazard index to help determine which grade crossings should

57 U.S. Department of Transportation, Federal Highway Administration, MUTCD 2000: Manual on

Uniform Traffic Control Devices, Millennium Edition (Washington, DC: FHWA, 2000).

58 Page 8B-7.

59 In 1999, the State installed 15 active warning devices.
Factual Information 32 Highway Accident Report

receive an active warning device or an upgrade of an existing device. The index includes

data such as the amount of railroad traffic, the amount of highway traffic, the speeds

involved, and grade crossing accident history. Because of the widely varying conditions

and circumstances at grade crossings (for example, types of vehicles using the crossing,

sight distance, and location), Tennessee uses a diagnostic team comprising employees of

the State department of transportation and the railroads to make the final selections.

Tennessee law requires that a railroad install an active warning device at a grade

crossing where a collision between a motor vehicle or pedestrian and a train results in a

fatality. Installation of the warning device is funded by the railroad, the State, and the

county or local municipality at a cost of about $150,000 for lights and gates.60 Before this

collision, the Liberty Church Road crossing had not been designated for improvement.

Following the accident, on September 9, 2000, it was upgraded to an active crossing with

gates and lights.

DOT Highway Rail Crossing Inventory and Hazard Index. The FRA compiles

and maintains the DOTís Highway Rail Crossing Inventory61 to assist the States in

conducting their own grade crossing safety programs. In examining the database, the

Safety Board found discrepancies between information contained in the database and

existing conditions at the accident crossing and other crossings in the area. Investigators

looked at 10 crossings in the Liberty Church Road vicinity and found that the inventory

listed the track speed as 10 mph less than the actual speed in seven instances and did not

list the track speed at all in one instance. The inventory listed 13 trains per day for five

crossings, 16 trains per day for four crossings, and did not list the number of trains for one

crossing. CSXT reported 30 to 35 trains traveling over each crossing daily.

States often use information from the inventory to develop a hazard index for

railroad/highway grade crossings. The FRA itself developed a Web-based Accident

Prediction System (WBAPS) that is based, in part, on information from the inventory, and

on data such as the type of warning device at the grade crossing, the exposure index,62 and

the number of accidents at the location in the past 5 years. A private company, under

contract to the FRA, completed an analysis of the WBAPS in June 1999, comparing the

performance of the FRA model to other models used to predict accidents. The study found

that differences were minimal and that no model retained a substantial edge over another.63

The public can use the WBAPS to help determine where best to direct highway grade

crossing resources.64 Law enforcement personnel can use the system to target unsafe

crossings for monitoring.

60 NTSB/SS-98/02.

61 Database intended to document every grade crossing in the United States

<http://safetydata.fra.dot.gov/officeofsafety/Crossing/Default.asp>.

62 The exposure index includes the number of trains per day, the number of cars traversing the grade

crossing, and the fastest train speed on the track.

63 May 8, 2000, letter from the Secretary of Transportation to the Chairman of the National

Transportation Safety Board.

64 U.S. Department of Transportation, Federal Railroad Administration, ìUsing Data Produced by

WBAPS Disclaimer.î
Factual Information 33 Highway Accident Report

According to an FRA official, about half the States have devised their own hazard

indexes for evaluating grade crossings. Tennessee uses the DOTís Rail Highway Crossing

Resource Allocation Procedure Userís Guide65 to prioritize crossings for upgrade. To

determine the hazard index of crossings, the guide applies the FRA accident prediction

formula, which is similar to the WBAPS. Under 23 CFR 924, States are required to

incorporate the relative hazard of railroad/highway grade crossings into their highway

safety improvement program based on a hazard index formula.

Initiatives Related to Passive Grade Crossings and School Buses. On

October 16, 2000, as a result of this accident, the Chairman suggested four safety

initiatives in a letter66 to the Governor of Tennessee that could be implemented to enhance

the safety of citizens at passive grade crossings. These four initiatives were:

Install warning devices at passive grade crossings

The Safety Board has recommended (Safety Recommendation H-98-34) that stop

signs be installed at all grade crossings that do not have active devices such as gates and

lights. The Chairman urged the Governor of Tennessee to consider immediately installing

warning devices at all passive crossings traversed daily by school buses.

Strengthen criteria for the installation of active warning devices

The Chairman encouraged the Governor to include the number and frequency with

which school buses cross passive grade crossings as a factor in determining whether to

install stop signs or active warning devices at those crossings.

Strengthen Tennesseeís CDL manual and exam to include questions related to

passive grade crossings

The Safety Board has recommended (Safety Recommendation H-98-37)67 that the

States include questions on safety at passive grade crossings in every version of the Statesí

written commercial driver license examinations to reinforce the actions that commercial

drivers, including school bus drivers, should take when encountering grade crossings.

Install noise reducing switches

In order to better hear the train horn at grade crossings, Florida and Kentucky are

in the process of installing manual ìoption kill switchesî in their school buses so that

65 DOT/FRA/OS-87/10.

66 See appendix B for the letter in its entirety.

67 Safety Recommendation H-98-37 requests that the States ìensure that questions on safety at passive

grade crossings are included in every version of the Stateís written drivers examination.î This

recommendation has been classified ìClosedóAcceptable Actionî for 3 States, ìClosedóAcceptable

Alternate Actionî for 10 States, ìOpenóAcceptable Responseî for 12 States, and ìOpenóUnacceptable

Responseî for 1 State. The Safety Board has yet to receive a response from 24 States, including Georgia and

Tennessee.
Factual Information 34 Highway Accident Report

drivers can turn off noise-producing devices, including fans and radios, when they come to

a grade crossing.

In-Vehicle Warning Systems

In-vehicle warning and advisory systems transmit alerts to highway vehicles to

warn of the presence of approaching trains. A two-point system consists of train-tovehicle communication, that is, a signal is broadcast by a transmitter on the locomotive to

a receiver on the approaching highway vehicle. A three-point system uses a roadside

device to detect a train and transmit the information to a vehicle-based receiver.68 The

addition of global positioning system (GPS) technology to either the two- or three-point

system can improve accuracy by providing the trainís estimated arrival time. Current

systems are designed to alert drivers no more than 20 seconds before a trainís arrival, the

same amount of time as drivers are alerted at active grade crossings.

In 1997, the Minnesota Department of Transportation tested a three-point system

in a school district in which 30 system-equipped buses each crossed two to five grade

crossings per day.69 School bus drivers were surveyed to determine their perception of the

system, and 80 percent of them thought that the system provided valuable warning

information; 15 percent reported that the system affected their driving behavior. One

survey respondent stated that the system helped her avoid a crash.70

In 2000, the Intelligent Transportation Systems Program Office of the Illinois

Department of Transportation conducted a pilot study of a three-point system at grade

crossings near Chicago. The 300 test vehicles included school buses, emergency service

vehicles, and commercial vehicles that regularly traversed five active grade crossings

where train detection devices were already in place. This study used off-the-shelf

technology and evaluated driver perceptions of on-board warning system effectiveness,

including the in-vehicle receiver position, warning display methods, and overall system

reliability.71

Final results from the Illinois study are due in spring 2002. According to the

system evaluator, preliminary results indicate that drivers liked getting the additional

warnings, although they would have preferred an earlier warning, before the lights and

gates were activated.72 One school bus driver said she liked the reassurance that the

systems gave her when she approached a grade crossing. Overall, the driversí impressions

68 Hoy A. Richards and Richard T. Bartoskewitz, The Intelligent Highway-Rail Intersection Integrating

ITS and ATCS for Improved Grade Crossing Operation and Safety (College Station, TX: Richards &

Associates and Texas Transportation Institute, April 1995).

69 Amy Polk, An In-Vehicle Signing System for School Buses at Rail-Highway Grade Crossings,

Minnesota Department of Transportation, 1996.

70 Amy Ellen Polk, ìThe Use of ITS to Improve Safety and Mobility at Highway-Rail Grade

Crossings,î <http://www.nawgits.com/icdn/its_hri.html>.

71 Pilot Study of Advisory On-Board Vehicle Warning Systems at Railroad Grade Crossings, Executive

Summary, Illinois Department of Transportation, 1997.

72 Dr. Ray Benekohol, Associate Professor of Civil Engineering, University of Illinois, July 18, 2001,

telephone conversation.
Factual Information 35 Highway Accident Report

were positive and they believed the device would be effective at passive grade crossings.

The in-vehicle device is projected to cost about $100. The transmitters used in the test cost

about $20,000 to $30,000, but the system evaluator believes the cost is likely to drop if

more are produced.

Automatic Crash Notification Systems

Automatic crash notification (ACN) systems are vehicle-based systems that detect

when a crash has occurred and then automatically notify the local 911 center. They can

reduce the time that elapses between the accident and the arrival of emergency response

personnel on scene.73 Some research indicates that reducing notification time from the

current average of 9 minutes after a crash to 1 minute would save an estimated 3,000 lives

per year.74

ACN systems can differ in both the way in which a crash is detected and the way

in which information is transmitted to an emergency response center. Some ACN systems

activate when the driverís airbag deploys (the driverís airbag does not deploy in certain

types of crashes, such as side impacts and rollovers). Other ACN systems use orthogonal

accelerometers, which activate the system when a certain deceleration threshold is reached

and can also provide an estimate of crash severity (such systems would detect accidents in

all types of crashes). Information can be transmitted either directly to local police or to a

customer service center (CSC), which functions as an intermediary between the vehicle

and a 911 center. If transmittal is through a CSC, the center can help determine the

severity of the crash and relay that information to the emergency responders. Direct

transmittal to the emergency responders can decrease response time.

Publicly sponsored tests using ACN systems have been conducted in Colorado,

Washington, Minnesota, and New York.75 Based on test results, researchers have identified

several areas that need improvement. First, ACN systems are heavily reliant on cellular

telephone coverage to open a communication line and to transmit data. In rural areas,

where ACN can have great impact, cellular coverage may be sparse, although even in

rural areas coverage is growing rapidly. Second, the interface between CSCs and 911

centers can pose a challenge. If a call goes to a CSC, the CSC must determine the closest

911 center to the accident and then place a 10-digit telephone call to that center. The CSC

itself cannot dial 911 because the call would go to the 911 center closest to the CSC, not

necessarily the one closest to the crash. Third, GPS accuracy has been an issue. When the

tests were conducted, nonmilitary GPS receivers could only provide geolocation

information within about 120 meters because of deliberate errors embedded in the signal.

These errors have since been removed, thereby increasing the accuracy of the systems.

73 <http://www.nhtsa.dot.gov/cars/problems/studies/acns/champion.htm>.

74 W. Evanco, ìReducing Accident Fatalities with Rural Mayday Systems,î Mitretek Systems, Inc.,

WN96W0000048, in U.S. Department of Transportation, Federal Highway Administration, Review of ITS

Benefits: Emerging Successes, FHWA-JPO-97-001, HVH 1/10-96(1M0) E (Washington, DC: FHWA, 1996)

19.

75 A. Blatt, E. Bellis, B. Donnelly, D. Funke, R. McClellan, and G. Wilson, Automated Collision

Notification, Final Report (Washington, DC: NHTSA, October 31, 2000).
Factual Information 36 Highway Accident Report

Cellular providers were required to provide geolocation ability for all calls by October

2001.76 The Federal Communications Commission extended this date (the new deadline

varies by carrier)77 when none of the carriers met the October 2001 deadline.

In March 1997, as part of the ACN system used in the New York operational test, a

software program, URGENCY,78 was developed to improve computer-assisted dispatch of

rescue resources. With the input of several parameters from crash data recorders, such as

crash force, type of crash, and passenger data, the software determines the likelihood of a

serious injury. This feature can help emergency responders determine the appropriate level

of response prior to arrival on scene.

The costs of ACN systems vary from $200 to $1,000 per vehicle, depending on

available options, including nonemergency services such as directions. ACN systems are

already available on some passenger cars and open a communication line with a CSC if

the airbag is deployed or the driver presses an emergency button. These systems

incorporate the vehicle-equipped GPS locating function.

76 <http://www.fcc.gov/e911/factsheet_requirements 012001.txt>.

77 <http://www.fcc.gov/bureaus/wireless/news_releases/2001/nw10127a.txt>.

78 <http://www.nhtsa.dot.gov/cars/problesm/studies/acns/champion.htm>.
37 Highway Accident Report

Analysis

General

During the past 30 years, Safety Board recommendations have led to significant

improvements in the transportation of school bus passengers. Statistically, school buses

are among the Nationís safest modes of transportation. Yet, as this accident demonstrates,

certain issues pertaining to school bus safety, although previously addressed by the Board,

continue to require attention.

In the following analysis, the Safety Board will first exclude factors that neither

caused nor contributed to the accident and then examine those factors that led to or had a

role in the accident. The discussion will focus on the school bus driverís performance;

school district oversight, including busdriver monitoring and evaluation procedures and

bus routing; passive grade crossing safety, including previous initiatives related to passive

grade crossing and school bus safety; school bus crashworthiness and survival factors,

including occupant kinematics; and emergency response.

Exclusions

The weather was clear and dry at the time of the accident and, although the sun had

just risen, neither the school bus driver nor the locomotive engineer identified the sun as

an impairment to visibility.

Neither maintenance records for the 1-year-old school bus, nor postaccident

inspection of the vehicle, indicated any mechanical problems that may have hampered

operation of the vehicle.

A review of daily track inspection records in the 6 months prior to the collision

showed no anomalies, and postaccident inspection of the track did not reveal any

problems. A review of maintenance records and inspections both before and after the

accident disclosed no mechanical problems with either the locomotive or the train.

The locomotive engineer and conductor were experienced in operating trains over

the territory in which this accident occurred. They tested the brakes, as required, and

complied with wayside signal indications and specified track speeds. Both the engineer

and conductor had passed numerous efficiency tests in the previous year, exceeding

Federal testing requirements. Data from the event recorder corroborated the engineerís

and conductorís statements about what they did prior to impact.
Analysis 38 Highway Accident Report

A survey of the accident site did not reveal sight restrictions. Investigators

calculated that the school bus driver had adequate distance to see the train had she stopped

as required.

Toxicological tests performed on the blood and urine specimens taken from the

train conductor, the engineer, and the busdriver were negative for alcohol and illicit drugs.

Toxicological tests of the busdriverís blood and urine specimens did reveal the presence of

phenylpropanolamine in the urine and the presence of pseudoephedrine and ephedrine in

both specimens.

Pseudoephedrine, a common decongestant with the trade name Sudafed, is found

in many over-the-counter cold and allergy preparations. It does not usually result in

impairment and has been shown to have stimulant effects. Ephedrine is sold as an overthe-counter asthma medication (trade name Primatene). It too does not usually result in

impairment and is a stimulant. Ephedrine and pseudoephedrine are often found together in

the herbal supplement Ma Huang, also known as ìephedra,î which is used as an ìenergy

booster,î stimulant, weight loss product, or decongestant in many nutritional supplements.

Phenylpropanolamine, an over-the-counter decongestant, is also marketed as a weight loss

product and is a metabolite of ephedrine and pseudoephedrine. The Food and Drug

Administration requested that manufacturers withdraw it from the market in November

2000 due to a very small, but measurable, increased risk for stroke associated with its use,

primarily in women taking it for weight loss. Nonetheless, phenylpropanolamine usually

does not result in impairment and has stimulant effects.

Therefore, the Safety Board concludes that the weather, the mechanical condition

of the school bus and train, and the condition of the track did not cause or contribute to the

accident; the locomotive engineer and conductor were qualified and complied with

Federal regulations; the sight distance along the tracks was adequate for the school bus

driver to see an oncoming train; and neither alcohol nor drugs was a factor in the accident.

Accident Analysis

Georgia and Tennessee law require that school bus drivers stop the bus before

crossing railroad tracks, open the door and window, turn off the radio, look both ways, and

proceed when clear. An analysis of the videotape found on the bus showed that the school

bus was traveling about 25 mph to 30 mph down Liberty Church Road and had reduced its

speed to about 15 mph prior to the crossing. The videotape also recorded the driverís

failure to stop. The window and door were not visible on the videotape, but no sounds

associated with opening either one were audible. Had the busdriver stopped 15 feet from

the crossing, as required, she would have been able to see 1,268 feet down the tracks and

to observe the approaching train. Had the busdriver turned off the radio and opened the

door and window, as required, she probably would have heard the train horn. The Safety

Board therefore concludes that if the busdriver had followed the required procedures at the

grade crossing, that is, if she had stopped at least 15 feet from the nearest rail, turned off
Analysis 39 Highway Accident Report

her radio, and opened the door and window, she would have seen and heard the train and

avoided the accident.

In a postaccident interview, the busdriver stated that she stopped, looked both

ways, opened the door, looked in her rear view mirror to make sure the passengers were

seated, then looked both ways down the track and proceeded. However, the school bus

videotape contradicts this statement. Nor was the busdriverís behavior on this occasion an

isolated incident; her actions were indicative of complacency at grade crossings. As

recorded on the accident bus videotapes, the driver drove over the same railroad crossing,

without stopping, eight other times. Another train engineer reported seeing a female

school bus driver cross the railroad tracks in front of his train at the same location on a

previous occasion, although he did not report the incident at the time that he witnessed it.

The accident driver was the only female school bus driver to regularly traverse the Liberty

Church Road crossing.

The Murray County School District provides annual recertification training for all

busdrivers. This training, which the accident driver had received on August 12, 1999,

includes information on what drivers are required to do at railroad/highway grade

crossings. The driver also received training on the same subject from her previous

employer and was reprimanded for talking during the lesson. The fact that the driver told

police investigators that she stopped and opened the door shows that she knew the

regulations for school buses crossing railroad tracks. The Safety Board concludes that

although the driver had been educated on and knew the mandatory safety precautions at

railroad/highway grade crossings, she disregarded the required procedures and crossed the

railroad tracks without stopping on the day of the accident and at least eight other times

before the accident.

The accident driver crossed the Liberty Church Road railroad tracks daily when

operating over her regular route. In its 1998 study on safety at passive grade crossings,79

the Safety Board concluded:

A driverís decision to look for a train may be adversely affected by the driverís

familiarity with and expectations at a specific passive grade crossing and the

driverís experience with passive crossings in general.

The accident busdriver may have become complacent; she had not stopped at the

crossing on at least eight other occasions and, therefore, even though trains passed this

crossing daily between 6:00 a.m. and 7:00 a.m., may not have perceived the danger

associated with railroad/highway grade crossings. The annual training she had received

apparently was insufficient to reinforce to the driver the hazards associated with grade

crossings.

79 NTSB/SS-98/02, p. 61.
Analysis 40 Highway Accident Report

On January 25, 1985, the Safety Board issued a recommendation on monitoring

school bus driver compliance at grade crossings to the state directors of pupil

transportation of the 50 States and the District of Columbia:

H-85-4

Encourage local school jurisdictions to establish and enforce procedures to

systematically monitor schoolbus driver compliance with railroad crossing stop

requirements and routing requirements which include on-scene observations of

driver performance.

Georgia responded that the superintendent or staff monitored each school bus route

annually and that drivers were encouraged to report any unsafe crossings. The

recommendation was classified ìClosedóAcceptable Actionî for Georgia on November

18, 1993.80 The NASDPTís National School Transportation Specifications and

Procedures recommends that pupil transportation directors monitor and evaluate school

bus drivers in the performance of their duties.81

Based on a review of the Murray County School District files, neither the accident

driver nor any other driver had been monitored or received a performance evaluation.

Observing and evaluating drivers allows problems to be detected and addressed before an

accident occurs. In this case, in which the driver had frequently ignored proper procedures

at passive grade crossings by crossing the tracks without stopping, ample opportunity

existed for the transportation director (or a representative) to have observed the driverís

behavior, reviewed the videotapes, or both, and taken corrective action.

While the videotapes are intended to monitor passenger behavior, they can also be

used to observe driver behavior and to educate drivers on proper actions, as necessary.

Without an evaluation program in place, the school district had no proactive means of

identifying drivers who were operating their buses in an unsafe manner. The Safety Board

concludes that the Murray County School District did not monitor drivers nor identify and

correct improper behavior, thus missing the opportunity to observe this driverís behavior

at railroad/highway grade crossings. Since the accident, Murray County has implemented

a program under which supervisors follow drivers who are operating school buses to

evaluate their performance. The county has also been working more closely with

Operation Lifesaver to provide mandatory driver training about grade crossing safety.

Grade Crossings

In its 1998 study on safety at passive grade crossings, the Safety Board

recommended that all passive grade crossings be equipped with highway stop signs, at a

80 Safety Recommendation H-85-4 is classified ìClosedóAcceptable Actionî for 48 States and the

District of Columbia and ìClosedóNo Longer Applicableî for 2 States.

81 The NASDPTS recommendation was in response to Safety Recommendations H-96-52 and -53.
Analysis 41 Highway Accident Report

minimum. Only Idaho and Hawaii have taken the initiative to install stop signs at all

passive grade crossings. In its September 8, 2000, response, the Tennessee Department of

Transportation reported that the Tennessee Highway/Railroad Grade Crossing Task Force

was studying the issue of placing stop signs at grade crossings and had already gathered

considerable data, particularly for school bus routes. Tennessee has enhanced safety at the

accident crossing by installing an active crossing warning device there; State law requires

that Tennessee install active warning devices where a fatality has occurred.

While eliminating railroad/highway grade crossings or activating them with lights

and gates is ideal, the Safety Board understands that activating crossings can be

expensive; installing stop signs is a less costly solution. Had the accident driver stopped

the school bus at the crossing and looked for the train, she would have been able to see it

and probably would not have crossed in front of it. The sight distance along the tracks for

a vehicle 15 feet from the crossing was sufficient to allow a stopped driver to see a train

approaching. While State laws already require that school bus drivers stop at all grade

crossings, drivers can benefit from being reminded about this requirement, and a stop sign

provides that reinforcement. Moreover, passengers riding the bus are unlikely to know that

all school buses are supposed to stop at grade crossings. If a stop sign is present, it is

possible that passengers may question a driver if he or she does not stop or may tell their

parents or teachers that the busdriver failed to stop, providing another means of oversight.

The Safety Board therefore concludes that had a stop sign been present at the crossing, it

would have reinforced to the driver the need to stop before crossing the tracks, likely

prompting her to stop and not attempt to cross in front of the train.

Auditory Alerts

Locomotive event recorder data indicate that the train horn was activated for about

3 seconds when the train was 952 feet from the crossing and then continuously for 9

seconds (a minimum of 574 feet) before the collision. The busdriver had the radio and

overhead speaker on. Additionally, the two panels above the driverís head were covered

with sound attenuation material. To be identified, a sound must be 3 to 9 decibels above

the threshold of detection;82 to reach the alerting level, it must be at least 10 decibels above

the ambient noise level.83 With the door closed and the radio on (the conditions at the time

of the accident), audibility testing revealed that the sound of the horn was only 5 decibels

greater than the ambient noise when the train was 1,268 feet from the crossing and was

barely detectable to the volunteer busdriver. Since the sound level increases by about 6

decibels when the distance is halved, at 574 feet, the sound of the horn would have been

about 11 decibels above the threshold of detection. During the accident, with the radio on

and the door and window closed, the audio portion of the videotape did not pick up the

sound of the horn over the ambient noise. During testing, with the radio off and the door

open, even at 1,268 feet, the sound level of the horn was 26 decibels above that of the

82 The ìthreshold of detectionî is the level at which a person is aware of a sound.

83 Stanley C. Skeiber, Robert L. Mason, and R. C. Potter ìEffectiveness of Audible Warning Devices on

Emergency Vehicles, Sound and Vibration,î February 1978, pp. 14-22.
Analysis 42 Highway Accident Report

ambient noise, and a driver would probably be able to detect the sound and be alerted to

the approaching train. Therefore, the Safety Board concludes that the driver did not stop,

had the radio on, and the door closed; thus she had difficulty detecting the train horn and

was probably unaware of the presence of the train.

The Safety Board made two recommendations concerning bus speakers to the

NASDPTS in the 1996 Fox River Grove highway accident report:

H-96-50

Develop guidelines for the appropriate placement of radio speakers and use of

radios on school buses and disseminate these guidelines to your members.

H-96-51

Advise your members to check their school district buses and disable any radio

speakers located immediately adjacent to the school bus driversí heads.

The NASDPTS informed the Safety Board that it had surveyed the States and

found that a majority of the States had prohibited, or had legislation pending that

prohibited, radio speakers in the driverís compartment. The remaining States reviewed

their policies on use of radios and radio speakers in school buses and stated that the

policies were adequate to ensure that drivers can hear critical auditory information.

Georgia informed its local school districts of the need to follow proper procedures,

including turning off speakers, when crossing railroad tracks. The State did not require

school districts to disconnect the speakers adjacent to the driverís head; Georgia left that

decision to the local school districts. In October 1998, the National Safety Council revised

its ìRecommended Procedures for School Bus Drivers at Railroad Grade Crossingsî to

remind drivers of the importance of turning off radios at railroad/highway grade crossings;

the revision was incorporated in the 2000 National School Transportation Specifications

and Procedures. Based on the NASDPTS survey and the associationís efforts to inform its

members of the hazards of not turning off the radio at grade crossings, Safety

Recommendations H-96-50 and -51 were classified ìClosedóAcceptable Alternate

Actionî84 on February 19, 1999.

Despite the NASDPTSís efforts, the 1-year-old school bus involved in this

accident was equipped with a radio speaker adjacent to the driverís head. In addition, the

driver did not follow prescribed policy to turn down the volume at railroad/highway grade

crossings. Consequently, the Safety Board believes that the Georgia Department of

Education should require all school districts to disconnect radio speakers used for music

or entertainment that are adjacent to school bus driversí heads. The Safety Board

understands from the NASDPTSís response to Safety Recommendations H-96-50 and -51

that the speakers are also used to transmit important information to the driver via two-way

84 The recommendations received this classification because the actions taken met the intent of the

recommendations, even though formal guidelines were not developed and school districts were reminded of

the hazards of speaker use when approaching railroad tracks, but were not specifically told to disable the

speakers.
Analysis 43 Highway Accident Report

radio from the school district dispatcher. While the Safety Board agrees that information

from the dispatcher is important, use of the speakers for music or entertainment broadcasts

is not critical and can hamper the driverís ability to hear external auditory alerts. Because

of the urgent need that drivers receive auditory alerts while operating a school bus, the

Safety Board believes that school bus manufacturers should discontinue the installation in

school buses of radio speakers used for music or entertainment that are adjacent to the

driverís head. The Safety Board further believes that NHTSA should implement

rulemaking to prohibit radio speakers used for music or entertainment from being placed

adjacent to driversí heads in school buses.

Speakers adjacent to a school bus driverís head probably contribute the most to

masking exterior sounds, such as train horns, but air conditioning, heaters, defrosters,

wiper motors, and other sounds also help mask exterior sounds. Therefore, Florida and

Kentucky have begun to install noise-canceling switches in school buses. The interrupttype switches are spring-loaded to prevent drivers from permanently overriding normal

operation of noise-producing equipment. When pressed, noise in the driverís area is

reduced, improving the driverís ability to listen for audible warnings. The Safety Board

concludes that if activated prior to a grade crossing, a switch that turns off all nonessential

noise-making components, including, but not limited to, the radio, can help drivers hear

train horns and stop as necessary.

In its Fox River Grove accident investigation report, the Safety Board

recommended that NHTSA:

H-96-43

Determine what effect school bus sound attenuation materials have on the ability

of a busdriver to discern both interior and exterior audible warnings.

NHTSA responded on April 22, 1997, that it would survey bus manufacturers on

the effect of sound attenuation materials, evaluate the data, and conduct testing, if

necessary. The agency also discussed in-vehicle warning systems that were undergoing

testing. Therefore, the Safety Board classified the recommendation ìOpenóAcceptable

Responseî on August 11, 1997.

Subsequently, on October 27, 2000, NHTSA wrote:

The agency does not believe that the use of specifications for sound attenuation

materials is the most effective approach for warning school bus drivers at railroad

crossings. Another means of preventing these types of tragic train-motor vehicle

collisions is by the use of in-vehicle warning systems. NHTSA believes that an

alternate solution to warn drivers at railroad grade crossings that a train is

approaching can be obtained by using intelligent transportation systems

technology. We plan to determine the applicability of this technology to warn

school bus drivers at railroad grade crossings that a train is approaching instead of

testing sound attenuation materials.
Analysis 44 Highway Accident Report

The Safety Board responded that while the installation of vehicle warning systems

is desirable for the future, the technology is still years away from implementation, and a

more active approach is needed to protect passengers being transported in school buses

over railroad crossings. Because of NHTSAís inaction in determining the effect of sound

attenuation materials, and the 4 years that had elapsed in the interim, the Safety Board

classified Safety Recommendation H-96-43 ìClosedóUnacceptable Actionî on April 18,

2001.

The accident school bus was equipped with sound attenuation material above the

driverís head. While it is unclear how much this material contributed to the driverís

inability to hear the train horn, it may have absorbed some of the horn sound. The Safety

Board remains concerned about the effects of sound attenuation material on a driverís

ability to hear an alerting signal. As explained in the Fox River Grove report,85 sound

attenuation material reduced the volume of both the train horn and the warnings shouted

by bus passengers in that accident.

In-Vehicle Warning Systems

An in-vehicle warning system receives information about an approaching train

either from the train itself or through the infrastructure and provides an auditory and visual

warning inside the vehicle to the driver. In its response to Safety Recommendation H-96-

43, NHTSA cited in-vehicle warning systems as a solution to the audibility problem that

drivers encounter when a vehicle is equipped with sound attenuation materials. NHTSA

stated that it would determine the applicability of such systems, which alert drivers to

oncoming trains, to school buses. Yet to date, no further testing of in-vehicle warning

systems for school buses has taken place, beyond the test completed in 2000 by the

Minnesota Department of Transportation and one that will be completed in 2002 by the

Illinois Department of Transportation that was not specific to school buses. This is the

only progress that has been made in this area to date. The Safety Board is pleased that the

DOT recognizes the importance of installing in-vehicle warning systems, but is concerned

about the pace at which such systems are being tested and installed in school buses.

Had the accident school bus been equipped with an in-vehicle warning system, the

driver may have realized that a train was approaching and may have stopped prior to the

crossing. An alert would have been activated as the bus approached the crossing (the

distance at which activation is triggered depends on the trainís speed but allows enough

time for a bus to stop prior to the crossing). The Safety Board concludes that an in-vehicle

warning system to alert drivers of the presence of an oncoming train would have provided

the busdriver with additional information, likely prompting her to stop before crossing the

tracks.

In its 1998 study on safety at passive grade crossings, the Safety Board

recommended that the DOT:

85 NTSB/HAR-96/02, p. 47.
Analysis 45 Highway Accident Report

I-98-1

Develop and implement a field test program for in-vehicle safety and advisory

warning systems, variable message signs, and other active devices; then ensure

that the private entities who are developing advanced technology applications

modify those applications as appropriate for use at passive grade crossings.

Following the modifications, take action to implement use of the advanced

technology applications.

On February 10, 1999, the Safety Board classified Safety Recommendation I-98-1

ìOpenóAcceptable Response,î based on the DOTís response that it is supporting

railroad/highway grade crossing projects in several locations. However, the DOT did not

specify how it planned to guide the implementation of such systems at passive grade

crossings and has provided no further response concerning this recommendation.

In the Safety Boardís opinion, the technologies described in the recommendation,

particularly in-vehicle warning systems, can help enhance school bus safety at passive

grade crossings. Therefore, the Safety Board is reiterating recommendation I-98-1 to the

DOT.

Grade Crossing Inventory and Hazard Prediction

The FRA maintains the nationwide grade crossing inventory. As part of the 1998

passive grade crossing study, the Safety Board made the following recommendation

concerning this system:

R-98-41

Modify the grade crossing inventory system to include information on (1) the

sight distances available to a motorist, and (2) the presence of curves on the

roadway and on the tracks. Direct the States to include these data as a part of the

regularly scheduled updates of the database.

Because the FRA updated the grade crossing inventory database to include

recommended elements, on January 4, 2000, the Safety Board classified Safety

Recommendation R-98-41 ìClosedóAcceptable Action.î However, as investigators

discovered, some information in the inventory is still outdated and incorrect. Of 10 sites in

the area of the accident crossing surveyed by Safety Board investigators, the inventory

listed incorrect maximum train speeds for 8 and incorrect number of trains per day for all

10.

In its April 6, 1999, response to Safety Recommendation R-98-41, the FRA stated

that such discrepancies occur because updating the information is voluntary and the FRA

lacks the authority to require States or railroads to upgrade information in the inventory.

The FRA has encouraged the States to provide up-to-date information for the inventory,

but the States have not done so. The FHWA gives funds to the States annually for highway
Analysis 46 Highway Accident Report

safety, including grade crossing safety and maintaining a survey of all grade crossings,

and provision of these funds could be contingent on updating the inventory regularly.

Because the States and others rely on this inventory for determining hazards and

predicting accidents at grade crossings, inaccurate information can lead to invalid

assessments. For example, the inventory lists the Liberty Church Road crossing as having

13 trains per day at a speed of 50 mph, which underestimates the 30 to 35 trains per day

passing through at a maximum of 60 mph. When these underestimates are factored into

equations that help users determine relative hazards, the resulting hazard index is similarly

understated and hazardous grade crossings may not be recognized as such. Therefore, the

Safety Board concludes that though critical to assessing grade crossing hazards, the data in

the Highway-Rail Grade Crossing Inventory are not always accurate and complete. The

Safety Board believes that the FHWA should require States to update the Highway-Rail

Crossing Inventory to accurately reflect current railroad operations.

About half the States use their own hazard index to determine priorities for

upgrading passive grade crossings to active crossings. Some, such as North Carolina, plan

to factor school buses into their formula. North Carolina has indicated that it will not only

consider whether school buses use a crossing but will also rank passive crossings

according to number of school bus trips over them and load data. Including such factors

assigns higher priority to school bus crossings and results in upgrading the safety of these

crossings more quickly than if the standard hazard index is used. At the time of the

accident, two school buses used the Liberty Church Road crossing daily. The Safety Board

concludes that had Tennessee factored school bus use into its grade crossing hazard index,

the accident crossing may have had a higher priority for receiving funds to install active

warning devices.

Although the WBAPS, the FRAís Web-based accident prediction system, is

primarily a tool for States to use in determining funding authority, law enforcement

agencies also use it to identify and monitor unsafe grade crossings. If the crossing

inventory in the WBAPS were accurate, school districts could also find the WBAPS

helpful in establishing school bus routes and identifying hazardous crossings. While the

inventory is not up-to-date, it represents the most comprehensive source of data available

and does permit hazard identification. Ideally, school bus routes should exclude passive

grade crossings; when that is not possible, the WBAPS or the Stateís own grade crossing

index could help school districts determine the least hazardous crossing. Such use further

emphasizes the need for maximum accuracy in these inventories. The Safety Board

concludes that the FRAís WBAPS or a Stateís grade crossing hazard index, as part of the

school bus routing hazard identification program, could help school districts select the

safest school bus routes. The Safety Board believes that the NASDPTS should encourage

its members to use the FRAís Web-based accident prediction system or the Statesí hazard

indexes for grade crossings when developing school bus routes.
Analysis 47 Highway Accident Report

School Bus Routing

In reviewing documents pertaining to Murray County school bus routes,

investigators determined that route hazards, including grade crossings, apparently were

not identified, nor were busdrivers told (other than through annual training) what actions

to take in the area of potential hazards. In 1996, the Safety Board recommended to the

NASDPTS:

H-96-52

Encourage your members to develop and implement a program for the

identification of school bus route hazards and to routinely monitor and evaluate all

regular and substitute school bus drivers.

In its response to the Safety Board, the NASDPTS stated:

Where it is possible to re-route the school bus to avoid a potential hazard, that is

the preferred action. Where it is not possible or feasible to change the school bus

route to avoid a potential hazard, then those hazards should be clearly and

prominently highlighted on the school bus route document that is provided to the

operator of the school bus. Additionally, a full description of what action(s) the

school bus driver should take in the area of the potential hazard should be

provided to the driverÖ. Drivers should be evaluated on a routine basis to ensure

that they remain knowledgeable on route hazard identification and action plans.

In June 1998, the NASDPTS, in cooperation with NHTSA, published guidance on

school bus routing that reflects its position as stated above and distributed the guidance to

States and localities. The Safety Board classified Safety Recommendation H-96-52

ìClosedóAcceptable Actionî on November 7, 1997. The guidance is also now part of the

National School Transportation Specifications and Procedures.

The Murray County transportation director has stated that all routes have been

reviewed since the accident and, as necessary, rerouted to use gated railroad crossings.

The routes were also reviewed and, as appropriate, adjusted for other hazards, such as

unsafe turns, curves, and pick-up and drop-off locations.

Safety Initiatives for Passive Grade Crossings and School Buses

Although the Safety Board has issued numerous recommendations, as previously

cited, to improve school bus and grade crossing safety, needless accidents, such as this one

at Conasauga, continue to occur. Following the accident, the Safety Board developed four

initiatives, based on previous safety recommendations that, if implemented by the States,

could reduce the number of grade crossing accidents involving school buses. Such a

program would include upgrading passive crossings, improving school bus routing,

monitoring driver performance, enhancing driver training and testing, and reducing the

noise inside the bus.
Analysis 48 Highway Accident Report

The Safety Board believes that the States, in cooperation with the NASDPTS,

should develop and implement a program of initiatives for passive grade crossings and

school buses that includes (1) installation of stop signs at passive crossings that are

traversed by school buses except where an engineering study shows their installation

would create a greater hazard; (2) use of information about whether school buses routinely

cross passive grade crossings as a factor in selecting crossings to upgrade with active

warning devices; (3) a requirement that all newly purchased and in-service school buses

be equipped with noise-reducing switches; (4) enhanced school bus driver training and

evaluation, including periodic reviews of on-board videotapes where available, especially

with regard to driver performance at grade crossings; and (5) incorporation of questions

on passive grade crossings in the CDL manual and examination.

Survival Factors and Occupant Kinematics

The school bus was extensively damaged during the collision, and the bus body

separated from the chassis behind the driverís seat. Within the passenger compartment, the

rows of seats in the impact area sustained massive crush damage, which decreased

longitudinally away from the impact area. The driverís seat separated from the body of the

bus and remained with the chassis, while the passenger seats remained within the body.

All window glazing on the passenger (impact) side of the bus was broken, while on the

driver side the window glazing remained intact, except for the first window. Despite

severe damage in the impact area of the bus, which is not unusual in a side impact

collision with a train locomotive at 51 mph, the bus body otherwise remained intact.

The MADYMO simulation generally showed that during the impact, the simulated

passengers rapidly traveled laterally and slightly forward toward the passenger side of the

bus. Those already seated on the passenger side quickly struck the sidewall and windows

of the bus, while those on the driver side typically struck the side of the adjacent seatback

and then continued across the width of the bus. The remainder of this section will discuss

both the evidence found on scene and the results of the occupant kinematics simulation.

During the accident, the lap-belted passenger received minor injuries, three

passengers (two of whom were ejected) received serious injuries, and three passengers

sustained fatal injuries (one of whom was ejected). The passenger seated behind the driver

in row two (seat 2A) was restrained by a lap belt and remained within the bus body. This

passenger sustained minor abdominal blunt force injuries along the line of the lap belt. In

the simulation, this passengerís upper body pivoted laterally toward the right and slightly

forward about the belt. Predicted injuries were low for this passenger when restrained by

the lap belt. Bruising is the most common injury from a lap belt and results from force

applied by either the diagonal or transverse lap strap.86 The lap belt acts as a fulcrum for

flailing of the upper body and lower extremities.87

86 Bernard Knight, Forensic Pathology (New York: Oxford University Press, 1991) 260.

87 J.K. Mason, The Pathology of Violent Injury (London: Edward Arnold, 1978) 28.
Analysis 49 Highway Accident Report

The availability of a lap belt restraint system and the size of this passenger (4 feet 5

inches tall and 117 pounds) enabled a properly fitted restraint system88 and permitted ridedown89 within the vehicle during this accident. In addition, this passenger remained within

the seating compartment90 and, unlike the two unbelted and ejected front-row passengers,

was not exposed to injury-causing objects and surfaces inside and outside the vehicle. The

Safety Board concludes that the lap belt-restrained passenger sustained minor abdominal

injuries as a result of the severity of the accident and the pivoting of her body about the lap

belt. Further, she was not ejected due to the use and proper fitting of the available restraint.

The two passengers ejected from the front row (seats 1A and 1F) sustained serious

injuries, including closed head injuries, and were seated in the area that was exposed

following separation of the bus body from the chassis. (The modesty panel in front of this

row remained intact). They were not wearing the available lap belts, did not remain within

the seating compartment, and, therefore, were ejected through the front opening of the bus

body during its rotation and deceleration. In addition, one of the two passengers (in seat

1F) was pinned underneath the front right corner of the bus body after it came to rest. The

simulation showed that during the initial collision, these passengers struck interior, nonenergy absorbing surfaces, including the side of the modesty panel91 (passenger in seat

1A) and the sidewall (passenger in seat 1F). The seats and the modesty panel conformed to

FMVSS 222 criteria for absorbing impact and dissipating collision energy from a

passenger striking the seat during a frontal impact. These standards were not developed

for a passenger striking the side of the seat in a lateral impact.

The passengers in seats 1A and 1F were then ejected and struck the exterior

surfaces at the same speed at which they were ejected from the vehicle. The full ride-down

effect was not afforded to these unbelted front-row passengers, particularly the passenger

in 1A, who was ejected shortly after separation. Although physical evidence was not

found that would have permitted investigators to determine what objects the passengers

struck to obtain their injuries, both passengers probably sustained serious injuries as a

result of having struck interior and exterior surfaces. The simulations predicted injuries to

these unrestrained front-row passengers as they contacted the side of the modesty panel

(passenger in seat 1A) and the sidewall of the bus (passenger in seat 1F). When restrained

88 Incorrectly adjusted or positioned straps can increase the danger of injury. Loose straps allow

movement of the body prior to the point at which restraint occurs. If a person, such as a child, is too small for

the lap belt, the body may slide from under the strap and sustain injury. See Bernard Knight, Forensic

Pathology (New York: Oxford University Press, 1991) 260.

89 Ride-down is the gradual deceleration experienced by passengers who remain within the

compartment of a vehicle and attached to the vehicle during its movement before coming to rest. If a

passenger is attached to the vehicle, he or she can take advantage of all the energy absorbed by the vehicle

later in the crash.

90 In school buses, compartmentalization protects passengers during frontal impacts. It affords this

protection through closely spaced seats, covering of the seat cushions and high seatbacks with an energyabsorbing material, and deformation of the seatback when impacted. The entire seat structure is designed to

absorb energy and to dissipate the energy of the crash away from the passenger and into the surrounding

compartment.

91 The modesty panels and seatbacks are designed to absorb energy in a frontal or rear collision.

Although the sides of the modesty panel and seatbacks are padded, there are no specifications for these to

absorb energy when struck during the lateral motion of an passenger.
Analysis 50 Highway Accident Report

by a lap belt only or a lap/shoulder belt, the passengers were retained within the seating

compartment, and the level of predicted injury was reduced for both passengers. The

Safety Board concludes that had the available restraints in the first row been worn in this

accident and had they fit properly, the two front-row passengers probably would not have

been ejected during the accident sequence and the level of injury may have been reduced.

The Safety Board also concludes that components within the passenger compartment that

are not fitted with energy-absorbing materials can contribute to serious injuries when

passengers strike them during an accident sequence.

Although the three passengers seated in the middle section of the bus remained

within the bus body during the accident, they sustained serious and fatal injuries. The

locomotive struck this section of the vehicle, resulting in major intrusion damage and

interior compartment deformation, thereby reducing the amount of survivable space. The

passenger seated on the driver side across from the impact area (seat 6A) was propelled

out of his seating compartment toward the intruding locomotive. He sustained a closed

head injury, right first rib fracture,92 and facial lacerations. The two passengers seated on

the passenger side of the bus (seats 6F and 8F) remained within their compartments; they

sustained blunt force trauma injuries to the head, thorax, and upper abdominal regions.

Although injuries were still predicted for the passenger across from the impact area (seat

6A), the simulation results indicated that the level of injury was reduced when a

lap/shoulder belt restrained this passenger. Furthermore, this passenger was retained

within the seating compartment and therefore not exposed to the interior deformation

when restrained by both the lap only belt and the lap/shoulder belt. The Safety Board

concludes that the seriously injured passenger across from the impact area (seat 6A)

sustained his injuries due to incomplete lateral compartmentalization and that all three

passengers (seats 6A, 6F, and 8F) in the impact area sustained injuries as a result of

locomotive intrusion and exposure to high impact forces.

Fiber evidence indicated that the rearmost-seated passenger on the driver side of

the bus (seat 12A) struck the side of the adjacent seatback and traveled laterally and

upward to the right. Blood evidence in the vehicle indicated that he then struck the right

sidewall and surface of the overhead storage rack support and frame. Postaccident

examination of this passenger, who was fatally injured, revealed chest abrasions and linear

contusions indicative of a contact injury; the pattern of these contusions matched the size

and shape of the window frame screw housing. Internal examination showed a transected

aorta93 and lacerated right atrium, in addition to multiple fractures and internal lacerations.

Although subsequently ejected from the bus, this passenger probably sustained his fatal

lacerated aortic injury within the vehicle during the first moments of the accident

sequence.

92 First rib fractures are rare unless extreme force is applied to the upper torso. See David Viano, Chest:

Anatomy, Types and Mechanisms of Injury, Tolerance Criteria and Limits, and Injury Factors, AAAM and

IRCOBI Biomechanics of Trauma Course Book, October 1997, p. 9.

93 The aorta is fixed and unyielding at the aortic ligament level, and this type of fatal injury is usually

seen in intersection-type crashes in which the jarring effect on the chest organs shears the aorta. From:

Werner U. Spitz, ed., Spitz and Fisherís Medicolegal Investigation of Death: Guidelines for the Application

of Pathology to Crime Investigation, Third Edition (Springfield, IL: Charles C. Thomas, 1993) 549.
Analysis 51 Highway Accident Report

The simulation showed that this passenger moved out of the driver side seating

compartment, struck the adjacent seatback, and continued laterally until the point of

impact with the window structure and sidewall, resulting in a predicted injury that

corresponded to the on-scene evidence. Simulation results indicated that the forces applied

to this passenger upon impact with the sidewall components were greater than those

applied to any other passenger away from the impact area in the bus, possibly due to the

high lateral and rotational accelerations at this seating location. Although this passenger

principally sustained blunt force trauma to the chest, the forces were sufficiently high that

the simulation predicted head, neck, and chest injuries when the passenger struck the

sidewall and window screw frame housing. A likely source of his fatal injury was the

passengerís deceleration into the non-energy absorbing interior surfaces, including the

interior right sidewall and the window frame screw housing, during the initial severe

lateral impact from the locomotive. The passenger struck these surfaces due to incomplete

compartmentalization in a lateral impact. Therefore, the Safety Board concludes that the

rearmost-seated passenger sustained fatal injuries due to movement out of the seating

compartment and subsequent impact with non-energy absorbing interior components.

Unlike the results from the passengers seated away from the impact area in the

front and center of the bus, the simulation predicted high levels of injury for the passenger

in seat 12A when restrained by a lap belt only and a lap/shoulder belt. The combination of

large lateral and rotational accelerations in this region of the bus caused this passenger to

decelerate rapidly, even when restrained, resulting in predicted injuries in all restraint

conditions. 

The following table (table 2) details the actual injuries sustained by the bus

passengers and the injuries predicted by the simulation. Although the injuries are not

identical, the trends are evident, especially for the passenger in seat 2A. This passenger

sustained only minor injuries during the accident sequence. The simulation indicated that

had this passenger not worn the available lap belt, the passenger would have been exposed

to a similar level of injury as the two front-row passengers.
Analysis 52 Highway Accident Report

Table 2. Summary of predicted injuries to the simulated occupants based on the bus 

simulation. 

On September 21, 1999, the Safety Board adopted a special investigation report on

bus crashworthiness issues94 in which the Board found that some passengers not seated in

the intrusion area were seriously or fatally injured in school buses involved in lateral

impacts with large vehicles. The Safety Board concluded:

Current compartmentalization is incomplete in that it does not protect school bus

passengers during lateral impacts with vehicles of large mass and in rollovers,

because in such accidents, passengers do not always remain completely within the

seating compartment.

Seating location Segment Actual injuries Unrestrained Lap belt only Lap/shoulder belt

1A (E) Head

Thorax

Neck

√

√

√

√

√

1F (E) Head

Thorax

Neck

√ √

√

√

√

√

√

2A (+) Head

Thorax

Neck

√

√

√

6A Head

Thorax

Neck

√

√

√

√

√

√

√

√

√

6F (*) Head

Thorax

Neck

√

√ √

√

√

√

√

√

√

8F (*) Head

Thorax

Neck

√ √

√

√

√

√

√

√

√

√

12A (*E) Head

Thorax

Neck

√

√

√

√

√

√

√

√

√

√

√ = predicted injury

* = fatally injured passenger

E = ejected passenger

+ = passenger wearing available restraint device

94 National Transportation Safety Board, Bus Crashworthiness Issues. Highway Special Investigation

Report NTHSB/SIR-99/04 (Washington, DC: NTSB, 1999).
Analysis 53 Highway Accident Report

The Safety Board recommended that NHTSA:

H-99-45

In 2 years, develop performance standards for school bus occupant protection

systems that account for frontal impact collisions, side impact collisions, rear

impact collisions, and rollovers.

NHTSA is conducting a study to develop ways to enhance the safety of the interior

environment for school bus passengers. The agency completed front and side impact fullscale crash testing in 2000 and is publishing the results. NHTSA expects to release its

research on frontal impact testing this winter. The side impact testing and research report

will not be completed until fall 2002. Safety Recommendation H-99-45 was classified

ìOpenóAcceptable Responseî on April 18, 2001. Preliminary results from the frontal

impact test showed that three available optionsóno restraint, lap belt only, and

lap/shoulder beltsóoffer varying degrees of benefit to the passenger and that passenger

size, seat spacing, and proper usage affect the protection capabilities of the restraint

system. Preliminary results from NHTSAís side impact crash test showed that crash test

dummies away from the impact area do not travel across the width of the bus and strike

the sidewall or other non-energy absorbing surfaces. Injury values were low for dummies

away from the impact area. 

In this accident, as well as other school bus accidents the Safety Board has

investigated, passengers sustained serious or fatal injuries due to impact with sidewall

components (differing from NHTSAís results). The unrestrained passengers on the driver

side of the bus in this accident were propelled out of their seating compartment and

received serious or fatal injuries as a result of such impacts. In several accidents discussed

in the Safety Boardís Bus Crashworthiness Issues report (Holmdel, New Jersey;

Monticello, Minnesota; and Easton, Maryland), passengers away from the impact area

were also propelled laterally out of their seating compartment and sustained serious and

fatal injuries due to contacting non-energy absorbing surfaces.

Even passengers seated on the same side as, but not in, the area of impact (such as

the passenger in seat 1F in this accident), have struck non-energy absorbing sidewalls and

components during a collision. In the Fox River Grove accident, a passenger seated away

from the impact area but on the same side of the bus as the impact sustained a fatal head

injury and an abrasion across the forehead that matched the perforated sound attenuation

panel pattern on the upper left side of the bus interior. The Safety Board concludes that

even those passengers who are outside the area of impact and remain within their

compartment can receive serious or fatal injuries due to impact with non-energy absorbing

components within a school bus.

Sidewall components, such as window frames, screws and joints, and overhead

storage rack supports are located throughout the interior of the passenger compartment, as

are the sides of the seatframes,95 yet are exempt from the Federal Motor Vehicle Safety

95 Or in the case of the first row in this accident, the modesty panels.
Analysis 54 Highway Accident Report

Standards for passenger protection in school buses. Although energy-absorbing materials

on the window frames, sidewall panels, roof racks, sides of seatframes and modesty panels

might benefit passengers who impact these locations, school bus passengers are not

afforded the benefit of energy-absorbing surfaces on these structures and components. If

these components were included in the passenger protection requirements of FMVSS 222,

ìSchool Bus Passenger Seating and Crash Protection,î passenger injuries would probably

be mitigated. The Safety Board concludes that FMVSS 222 exempts sidewall components

and sides of seatframes within the passenger compartment of school buses, thereby

exposing passengers to these injury-producing components in lateral impact collisions.

The Safety Board believes that NHTSA should develop and incorporate into the Federal

Motor Vehicle Safety Standards performance standards for school buses that address

passenger protection for sidewalls, sidewall components, and seatframes.

In this accident, the school bus body separated from the chassis. The separation

and subsequent distance traveled by the bus body are likely to have provided further ridedown for passengers after the collision, although the separation resulted in an opening at

the front of the body through which the two passengers and driver were ejected. In other

accidents96 the Safety Board has investigated, the body and chassis have also separated,

providing similar ride-down benefits to passengers remaining within the bus body. What

the Safety Board observed in this accident, but not in others, is the unique location in

which the body and chassis separated. In the Conasauga accident vehicle, the school bus

body separated behind the driverís seat; the engine cowling, front floor, and driverís seat

remained attached to the chassis. In other school bus accidents, the complete body

(including the driverís seat and flooring) and chassis have separated from one another. The

location of the body separation in this accident probably occurred because of the busís

movement immediately following the collision. Tire marks on the inside of the rail

indicated that the school bus wheels were temporarily hung up on the track as the bus

rotated away from the striking train. The tire catching on the rails may have initially

induced the separation between the body and chassis. The location of the separation,

behind the driverís seat, may have resulted from the impact with the railroad cross buck

near that location and from the fact that the body is attached to the chassis by more rigid

bolts under the driverís seat than at other locations.

The Safety Board has investigated two other accidents97 involving bus bodychassis separation in which the driverís seat was equipped with a lap/shoulder belt. In

both, the body and chassis separated completely and the driverís seat and belt system

remained with the bus body. In neither accident did the lap/shoulder belt become separated

between the anchor points. Both the lap and shoulder belts remained intact and attached to

the body of the bus.

96 Rehobeth, Massachusetts, January 10, 1984 (DCA-84-FH-005); Carrsville, Virginia, April 12, 1984

(DCA-84-AH-008); Palm Springs, California, July 31, 1991 (DCA-91-MH-005); Fox River Grove, Illinois,

October 25, 1995 (CRH-96-MH-002); and Buffalo, Montana, March 10, 1998 (HWY-98-MH-022).

97 Fox River Grove, Illinois (CRH-96-MH-002), and Buffalo, Montana (HWY-98-MH-022). Both

involved AmTran school buses.
Analysis 55 Highway Accident Report

In this accident, the upper anchorage (D-ring) and emergency retractor of the

driverís continuous lap/shoulder belt was mounted to the bus body side panel

approximately 16 inches behind the driverís seat. The lower anchorages were mounted to

the seat and attached to the floor with tethers directly under the driverís seat. When the

body separated, the driverís seat, the seat-mounted lap belt components, and part of the

lap/shoulder belt remained with the chassis, while the D-ring mounted on the sidewall and

part of the shoulder belt remained with the bus body. The body separation resulted in high

forces exerted on the belt webbing system, which tore, and the driver was ejected from the

separating vehicle components. The driver sustained minor injuries.

Because the driverís lap/shoulder belt was attached to both the bus body floor and

the sidewall, with one anchor point remaining with the body and the others with the

chassis, great forces were exerted on the belt. When the distance between anchor points is

broad and the body separates anywhere between these points, the webbing may cause

injury to the driver because of forces exerted on the webbing as the two components

separate. In this accident, the webbing failed, and the driver was ejected before the belt

exerted serious or fatal forces on her. While the Safety Board has not seen body

separations in this location before, it is concerned that drivers can sustain serious or fatal

injuries if the lap/shoulder belt anchor points are sufficiently far apart that a vehicle

separation between the points results in extreme forces exerted on the driver by the

webbing during an accident. The Safety Board concludes that the driverís lap/shoulder

belt webbing failed due to the high forces applied to the webbing as the two parts of the

school bus separated and due to the large distance between the lap/shoulder belt anchor

points.

Manufacturers should be aware of the potential consequences associated with

lap/shoulder belt anchor points that are far apart. If the anchor points are closer together,

the likelihood of a body separation occurring between them can be reduced, thereby

lessening the risk of injury. The NASDPTSís School Bus Manufacturers Technical

Council functions as an industry advisor to school bus manufacturers and the Safety Board

believes that it should notify its members of how and why the driverís lap/shoulder belt

tore in this accident and of the potential consequences of large longitudinal distances

between lap/shoulder belt anchor points.

Emergency Response

Almost immediately after the accident, a passerby placed a 911 cellular telephone

call and reported the accident. Even though the accident occurred in Polk County,

Tennessee, the call was routed to the Murray County, Georgia, 911 Center because the

cellular tower automatically relayed the cellular call to the closest 911 center. EMS units,

located within 2 miles of the scene, were immediately dispatched and arrived on scene

within minutes. The caller did not know the exact location of the accident because Polk

County does not have street signs. Emergency response was not hindered because the

caller was familiar with the area and described it in sufficient detail that emergency

responders immediately identified where the accident occurred. The caller also called
Analysis 56 Highway Accident Report

back 4 minutes later, after she went to St. Claireís gas station and learned the name of the

street.

The CSXT Police Communications Center placed its emergency call to local

police about 7 minutes after the accident. No other calls reporting the accident were

recorded.

The accident occurred in a rural area where traffic is not heavy. An ACN system

on the school bus would have detected the crash immediately and transmitted the crash

information, as well as the precise location, obtained via GPS, to the local 911 center. Had

such a system been in place, the school bus passengers would not have had to rely on a

passerby to place the call or on the driver, who was incapacitated, to call 911. In this

accident, the locomotive conductor notified CSXT of the accident, and CSXT then

notified the 911 center; but not all accidents involve vehicles in which the driver (or in this

case the train crew) is able to place an emergency call.

Because school buses often carry many children, quick and adequate emergency

response is important if all children are to be treated expeditiously, particularly those with

serious injuries. The more information provided to an emergency dispatch center, the

better the response is likely to be. An ACN system can transmit information on the

severity of the crash, the vehicle dynamics, and the location. Some systems include a

voice communication line that automatically opens so that the emergency response center

can communicate directly with the driver, if the driver is capable. If the school bus in this

accident had been equipped with an ACN system, a call would have immediately been

forwarded to the 911 center, either directly or through a relay center, and the 911

dispatcher would have known the exact location of the accident. A more advanced ACN

system would have relayed information about the severity of the crash, indicating to the

dispatcher a need to send multiple responders. The time lag would most likely have been

less than 2 minutes from the time of the collision to the time when emergency response

was dispatched.

Currently available ACN systems have helped reduce emergency response time,

thereby leading to more lives saved.98 In the operational test in New York, an emergency

notification was sent to the sheriffís office within 2 minutes of the accidents that

occurred.99 Cellular telephone system coverage has expanded and geolocation systems

have become more accurate; as a result, ACN system accuracy has improved. While the

school bus passengers in this accident were fortunate in the actions of a quick-thinking

passerby and a train crew that was able to place an emergency call, severe accidents,

particularly in rural areas, do not always occur in such circumstances.

98 W. Evanco ìReducing Accident Fatalities with Rural Mayday Systems,î Mitretek Systems, Inc.

WN96W0000048, April 1996, in U.S. Department of Transportation, Federal Highway Administration,

Review of ITS Benefits: Emerging Successes, FHWA-JPO-97-001, HVH 1/10-96(1M0) E (Washington, DC:

FHWA) 19.

99 B. Donnelly, D. Schabel, A.J. Blatt, and A. Carter, ìThe Automated Collision Notification System.î

International Symposium on Transportation Recorders, May 3-5, 1999 (Washington, DC: NTSB and

International Transportation Safety Association, 1999).
Analysis 57 Highway Accident Report

The Safety Board concludes that, in spite of a lack of street signs or a street

address, emergency responders to this accident were able to efficiently coordinate their

response operations and provided timely, appropriate medical services and rescue

operations, in part because of the 911 callerís prompt action and familiarity with the

accident area. However, in other accidents, passersby may not be present or callers

contacting a 911 center may not be familiar with the local area. In such situations, ACN

systems can help emergency call centers dispatch emergency responders to locations more

expeditiously, particularly in rural areas or when drivers are incapacitated. The Safety

Board concludes that, given the limited amount of traffic traversing Liberty Church Road,

emergency response might have been delayed if the passerby had not noticed the accident

or if the train crew had been incapacitated. While ACN systems are already available on

cars, testing of such systems on school buses has yet to be done. While the cellular and

GPS technology would be compatible with any vehicle, testing of ACN systems on school

buses is needed to evaluate factors such as vehicle dynamics and crash severity. The

Safety Board believes that NHTSA should evaluate the feasibility of incorporating ACN

systems on school buses and, if feasible, proceed with system development.
58 Highway Accident Report

Conclusions

Findings

1. The weather, the mechanical condition of the school bus and train, and the condition

of the track did not cause or contribute to the accident; the locomotive engineer and

conductor were qualified and complied with Federal regulations; the sight distance

along the tracks was adequate for the school bus driver to see an oncoming train; and

neither alcohol nor drugs was a factor in the accident.

2. If the busdriver had followed the required procedures at the grade crossing, that is, if

she had stopped at least 15 feet from the nearest rail, turned off her radio, and opened

the door and window, she would have seen and heard the train and avoided the

accident.

3. The driver did not stop, had the radio on, and the door closed; thus she had difficulty

detecting the train horn and was probably unaware of the presence of the train.

4. Although the driver had been educated on and knew the mandatory safety precautions

at railroad/highway grade crossings, she disregarded the required procedures and

crossed the railroad tracks without stopping on the day of the accident and at least

eight other times before the accident.

5. The Murray County School District did not monitor drivers nor identify and correct

improper behavior, thus missing the opportunity to observe this driverís behavior at

railroad/highway grade crossings.

6. Had a stop sign been present at the crossing, it would have reinforced to the driver the

need to stop before crossing the tracks, likely prompting her to stop and not attempt to

cross in front of the train.

7. If activated prior to a grade crossing, a switch that turns off all nonessential noisemaking components, including, but not limited to, the radio, can help drivers hear

train horns and stop as necessary.

8. An in-vehicle warning system to alert drivers of the presence of an oncoming train

would have provided the busdriver with additional information, likely prompting her

to stop before crossing the tracks.

9. Though critical to assessing grade crossing hazards, the data in the Highway-Rail

Grade Crossing Inventory are not always accurate and complete.
Conclusions 59 Highway Accident Report

10. Had Tennessee factored school bus use into its grade crossing hazard index, the

accident crossing may have had a higher priority for receiving funds to install active

warning devices.

11. The Federal Railroad Administrationís Web-based Accident Prediction System or a

Stateís grade crossing hazard index, as part of the school bus routing hazard

identification program, could help school districts select the safest school bus routes.

12. The lap belt-restrained passenger sustained minor abdominal injuries as a result of the

severity of the accident and the pivoting of her body about the lap belt; she was not

ejected due to the use and proper fitting of the available restraint.

13. Had the available restraints in the first row been appropriately worn in this accident

and had they fit properly, the two front-row passengers probably would not have been

ejected during the accident sequence and the level of injury may have been reduced.

14. Components within the passenger compartment that are not fitted with energyabsorbing materials can contribute to serious injuries when passengers strike them

during an accident sequence.

15. The seriously injured passenger across from the impact area (seat 6A) sustained his

injuries due to incomplete lateral compartmentalization, and all three passengers

(seats 6A, 6F, and 8F) in the impact area sustained injuries as a result of locomotive

intrusion and exposure to high impact forces.

16. The rearmost-seated passenger sustained fatal injuries due to movement out of the

seating compartment and subsequent impact with non-energy absorbing interior

components.

17. Even those passengers who are outside the area of impact and remain within their

compartment can receive serious or fatal injuries due to impact with non-energy

absorbing components within a school bus.

18. Federal Motor Vehicle Safety Standard 222 exempts sidewall components and sides

of seatframes within the passenger compartment of school buses, thereby exposing

passengers to these injury-producing components in lateral impact collisions.

19. The driverís lap/shoulder belt webbing failed due to the high forces applied to the

webbing as the two parts of the school bus separated and due to the large distance

between the lap/shoulder belt anchor points.

20. In spite of a lack of street name signs or a street address, emergency responders to this

accident were able to efficiently coordinate their response operations and provided

timely, appropriate medical services and rescue operations, in part because of the 911

callerís prompt action and familiarity with the accident area.
Conclusions 60 Highway Accident Report

21. Given the limited amount of traffic traversing Liberty Church Road, emergency

response might have been delayed if the passerby had not noticed the accident or if

the train crew had been incapacitated.

Probable Cause

The National Transportation Safety Board determines that the probable cause of

the collision was the school bus driverís failure to stop before traversing the

railroad/highway grade crossing. Contributing to the accident was the Murray County,

Georgia, School Districtís failure to monitor busdriver performance and its lack of school

bus route planning to identify hazards on school bus routes and to eliminate the necessity

of crossing railroad tracks. Contributing to the injuries of the school bus passengers

outside of the area of intrusion were incomplete compartmentalization and a lack of

energy-absorbing material on interior surfaces.
61 Highway Accident Report

Recommendations

To the States:

In cooperation with the National Association of State Directors of Pupil

Transportation Services, develop and implement a program of initiatives

for passive grade crossings and school buses that includes (1) installation

of stop signs at passive crossings that are traversed by school buses except

where an engineering study shows their installation would create a greater

hazard; (2) use of information about whether school buses routinely cross

passive grade crossings as a factor in selecting crossings to upgrade with

active warning devices; (3) a requirement that all newly purchased and inservice school buses be equipped with noise-reducing switches; (4)

enhanced school bus driver training and evaluation, including periodic

reviews of on-board videotapes where available, especially with regard to

driver performance at grade crossings; and (5) incorporation of questions

on passive grade crossings in the commercial driverís license manual and

examination. (H-01-38)

To the National Highway Traffic Safety Administration:

Implement rulemaking to prohibit radio speakers used for music or

entertainment from being placed adjacent to driversí heads in school buses.

(H-01-39)

Develop and incorporate into the Federal Motor Vehicle Safety Standards

performance standards for school buses that address passenger protection

for sidewalls, sidewall components, and seatframes. (H-01-40)

Evaluate the feasibility of incorporating automatic crash notification

systems on school buses and, if feasible, proceed with system

development. (H-01-41)

To the Federal Highway Administration:

Require States to update the Highway-Rail Crossing Inventory to

accurately reflect current railroad operations. (H-01-42)

To the Georgia Department of Education:

Require all school districts to disconnect radio speakers used for music or

entertainment that are adjacent to school bus driversí heads. (H-01-43)
Recommendations 62 Highway Accident Report

To the National Association of State Directors of Pupil Transportation Services:

Encourage your members to use the Federal Railroad Administrationís

Web-based accident prediction system or the Statesí hazard indexes for

grade crossings when developing school bus routes. (H-01-44)

In cooperation with the States, develop and implement a program of

initiatives for passive grade crossings and school buses that includes (1)

installation of stop signs at passive crossings that are traversed by school

buses except where an engineering study shows their installation would

create a greater hazard; (2) use of information about whether school buses

routinely cross passive grade crossings as a factor in selecting crossings to

upgrade with active warning devices; (3) a requirement that all newly

purchased school buses and in-service school buses be equipped with

noise-reducing switches; (4) enhanced school bus driver training and

evaluation, including periodic reviews of on-board videotapes where

available, especially with regard to driver performance at grade crossings;

and (5) incorporation of questions on passive grade crossings in the

commercial driverís license manual and examination. (H-01-45)

Notify your members of how and why the driverís lap/shoulder belt tore in

this accident and of the potential consequences of large longitudinal

distances between lap/shoulder belt anchor points. (H-01-46)

To the School Bus Manufacturers:

Discontinue the installation in school buses of radio speakers used for

music or entertainment that are adjacent to the driverís head. (H-01-47)

The National Transportation Safety Board also reiterates the following

recommendation:

To the U.S. Department of Transportation:

Develop and implement a field test program for in-vehicle safety and

advisory warning systems, variable message signs, and other active

devices; then ensure that the private entities who are developing advance

technology applications modify those applications as appropriate for use at

passive grade crossings. Following the modifications, take action to

implement use of the advanced technology applications. (I-98-01)
Recommendations 63 Highway Accident Report

BY THE NATIONAL TRANSPORTATION SAFETY BOARD

MARION C. BLAKEY

Chairman

CAROL J. CARMODY

Vice Chairman

JOHN A. HAMMERSCHMIDT

Member 

JOHN J. GOGLIA

Member

GEORGE W. BLACK, JR.

Member

Adopted: December 11, 2001
64 Highway Accident Report

Appendix A

Investigation and Public Hearing

The National Transportation Safety Board was notified of the Conasauga,

Tennessee, accident about 8:00 a.m. on March 28, 2000. An investigative team was

dispatched with members from the Washington, D.C.; Atlanta, Georgia; Parsippany, New

Jersey; and Fort Worth, Texas, offices. Groups were established to investigate human

performance; motor carrier operations; highway, vehicle, and survival factors; and

recorders and to document the scene.

Participating in the investigation were representatives of the National Highway

Traffic Safety Administration; the Federal Motor Carrier Safety Administration; the

Federal Railroad Administration; the Tennessee Highway Patrol; the Polk County,

Tennessee, District Attorney; CSX Transportation, Inc.; and the Murray County, Georgia,

School District.

No public hearing was held; no depositions were taken.
65 Highway Accident Report

Appendix B

October 2000 Letter to the Governor of Tennessee From the 

Chairman, National Transportation Safety Board
Appendix B 66 Highway Accident Report
Appendix B 67 Highway Accident Report