highway

Motorcoach Override of Elevated Exit Ramp

Interstate 75

Atlanta, Georgia

March 2, 2007

ACCIDENT REPORT

NTSB/HAR-08/01

PB2008-916201 National

Transportation

Safety Board

National

Transportation

Safety Board

490 L’Enfant Plaza, S.W.

Washington, D.C. 20594

Highway Accident Report

Motorcoach Override of Elevated Exit Ramp

Interstate 75

Atlanta, Georgia

March 2, 2007

490 L’Enfant Plaza, S.W.

Washington, D.C. 20594

NTSB/HAR-08/01

PB2008-916201

Notation 8021A

July 8, 2008
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Board reports related to an incident or accident in a civil action for damages resulting from a matter mentioned in the report.

National Transportation Safety Board. 2008. Motorcoach Override of Elevated Exit Ramp, 

Interstate 75, Atlanta, Georgia, March 2, 2007. Highway Accident Report NTSB/HAR-08/01. 

Washington, DC.

Abstract: About 5:38 a.m. eastern standard time on Friday, March 2, 2007, a 2000 VanHool T2145 

57-passenger motorcoach operated by Executive Coach Luxury Travel, Inc., transporting 33 members of 

the Bluffton University baseball team, the driver, and his wife, was traveling south on Interstate 75 in 

Atlanta, Georgia. According to witnesses, the motorcoach was in the southbound high occupancy vehicle 

(HOV) lane at milepost 250 when it departed the interstate, traveling at highway speed, onto the HOV-only 

left exit ramp to Northside Drive. The exit ramp came to an end at the stop sign-controlled T-intersection 

with Northside Drive. As the motorcoach entered the intersection at an estimated speed of 50 to 60 mph, 

the driver steered to the right and collided with the reinforced portland cement concrete bridge wall 

and chain-link security fence located along the southern edge of the eastbound lanes of the overpass. 

The motorcoach then overrode the bridge rail, rotated clockwise, and fell 19 feet onto the southbound 

lanes of the interstate. The motorcoach came to rest on its left side (driver’s side), perpendicular to the 

southbound lanes of Interstate 75. Two southbound passenger vehicles received minor damage from 

debris as the motorcoach fell onto Interstate 75; none of the passenger vehicle occupants were injured. 

Seven motorcoach occupants were killed: the driver, the driver’s wife, and five passengers. Seven other 

passengers received serious injuries, and 21 passengers received minor injuries.

Major safety issues identified in this accident include inadequate HOV traffic control devices, inadequate 

motor carrier driver oversight, lack of event data recorders on motorcoaches, and lack of motorcoach 

occupant protection. As a result of its investigation, the Safety Board makes recommendations to the 

Federal Highway Administration and to the Georgia Department of Transportation. The Safety Board 

also reiterates four previous recommendations to the National Highway Traffic Safety Administration.
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Contents

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

Executive Summary ......................................................................................................vii

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

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

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

Emergency Response ..............................................................................................................9

Driver Information..................................................................................................................9

Experience and Work History ..........................................................................................9

Work/Rest Schedule ........................................................................................................10

Medical and Pathological Information..........................................................................11

Vehicle Information ..............................................................................................................12

Vehicle Damage ................................................................................................................13

Accident Reconstruction..................................................................................................14

Motor Carrier Operation ......................................................................................................15

Meteorological Information.................................................................................................18

Speed Study............................................................................................................................18

Traffic Volume .......................................................................................................................18

Road Design ...........................................................................................................................18

Left Exits ............................................................................................................................19

Roadway Alignment........................................................................................................19

Lighting and Sight Distance............................................................................................20

I-75 and I-85 HOV Merge ................................................................................................22

Accident Location History ...................................................................................................22

Traffic Control Devices and Guidance ...............................................................................23

Signage and Pavement Markings Approaching Accident Location..............................25

Guide Signs for I-75 HOV Traffic...................................................................................25

Stop Signs at the Northside Drive Intersection............................................................28

Pavement Markings .........................................................................................................30

Postaccident Traffic Control Device Changes ...................................................................32

Analysis............................................................................................................................33

Exclusions ...............................................................................................................................33

Accident Discussion..............................................................................................................34

Inadequate Signage at Northside Drive Exit................................................................35

Inadequate Pavement Markings at Northside Drive Exit ..........................................37

HOV Traffic Control Devices...............................................................................................38

Driver’s Medical Condition .................................................................................................39

Medical Certification.............................................................................................................41

Motor Carrier Driver Oversight..........................................................................................42

Event Data Recorders............................................................................................................43
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Survival Aspects and Motorcoach Occupant Protection.................................................48

Occupant Protection Initiatives ......................................................................................49

Past Investigations and Actions .....................................................................................51

Conclusions.....................................................................................................................53

Findings ..................................................................................................................................53

Probable Cause ......................................................................................................................55

Recommendations..........................................................................................................56

New Recommendations .......................................................................................................56

Reiterated Recommendations..............................................................................................57

Board Member Statement.............................................................................................59

Appendixes

A: Investigation .....................................................................................................................63

B: Accident History for the Northside Drive Exit, 1997–2007........................................64

C: Safety Board Motorcoach Accident Investigations .....................................................65
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Acronyms and Abbreviations

AASHTO American Association of State Highway and 

Transportation Officials

CAMI Civil Aerospace Medical Institute

CDL commercial driver’s license

CFR Code of Federal Regulations

CSA 2010 Comprehensive Safety Analysis 2010

CVSA Commercial Vehicle Safety Alliance

ECE Economic Commission for Europe

EDR event data recorder

EU European Union

Executive Coach Executive Coach Luxury Travel, Inc.

FHWA Federal Highway Administration

FMCSA Federal Motor Carrier Safety Administration

FMVSS Federal Motor Vehicle Safety Standard

GAO Government Accountability Office

GDOT Georgia Department of Transportation

HOV high occupancy vehicle

I-75 Interstate 75

I-85 Interstate 85

IEEE Institute of Electrical and Electronics Engineers, Inc.

MCMIS Motor Carrier Management Information System

MUTCD Manual on Uniform Traffic Control Devices

NCHRP National Cooperative Highway Research Program

NHTSA National Highway Traffic Safety Administration

NPA notice of proposed amendments

SAE SAE International

SAFER Safety and Fitness Electronic Records

TRB Transportation Research Board

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Executive Summary

About 5:38 a.m. eastern standard time on Friday, March 2, 2007, a 2000 

VanHool T2145 57-passenger motorcoach operated by Executive Coach Luxury 

Travel, Inc., transporting 33 members of the Bluffton University baseball team, 

the driver, and his wife, was traveling south on Interstate 75 in Atlanta, Georgia. 

The motorcoach had departed from the university, about 60 miles southwest of 

Toledo, Ohio, about 7:00 p.m. the previous day and was en route to a competition 

in Sarasota, Florida. When the original driver had stopped in Adairsville, Georgia, 

approximately halfway through the 18-hour trip, the 65-year-old relief driver, 

accompanied by his wife, boarded the motorcoach and began driving at 4:30 a.m. 

to complete the trip to Florida. The relief driver had driven approximately 54 miles 

and, according to witnesses, was in the southbound high occupancy vehicle (HOV) 

lane at milepost 250 when the motorcoach departed the interstate, traveling at 

highway speed, onto the HOV-only left exit ramp to Northside Drive.

The exit ramp came to an end at the stop sign-controlled T-intersection with 

Northside Drive. As the motorcoach entered the intersection at an estimated speed 

of 50 to 60 mph, the driver steered to the right and collided with the reinforced 

portland cement concrete bridge wall and chain-link security fence located along 

the southern edge of the eastbound lanes of the overpass. The motorcoach then 

overrode the bridge rail, rotated clockwise, and fell 19 feet onto the southbound 

lanes of the interstate. The motorcoach came to rest on its left side (driver’s 

side), perpendicular to the southbound lanes of Interstate 75. Two southbound 

passenger vehicles received minor damage from debris as the motorcoach fell onto 

Interstate 75; none of the passenger vehicle occupants were injured. Seven 

motorcoach occupants were killed: the driver, the driver’s wife, and five passengers. 

Seven other passengers received serious injuries, and 21 passengers received minor 

injuries.

The National Transportation Safety Board determines that the probable 

cause of this accident was the motorcoach driver’s mistaking the HOV-only left 

exit ramp to Northside Drive for the southbound Interstate 75 HOV through lane. 

Contributing to the accident driver’s route mistake was the failure of the Georgia 

Department of Transportation to install adequate traffic control devices to identify 

the separation and divergence of the Northside Drive HOV-only left exit ramp 

from the southbound Interstate 75 HOV through lane. Contributing to the severity 

of the accident was the motorcoach’s lack of an adequate occupant protection 

system.

Major safety issues identified in this accident include inadequate HOV 

traffic control devices, inadequate motor carrier driver oversight, lack of event 
Executive Summary

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data recorders on motorcoaches, and lack of motorcoach occupant protection. As a 

result of its investigation, the Safety Board makes recommendations to the Federal 

Highway Administration and to the Georgia Department of Transportation. The 

Safety Board also reiterates four recommendations to the National Highway Traffic 

Safety Administration.
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Factual Information

Accident Narrative

About 5:38 a.m. eastern standard time on Friday, March 2, 2007, a 2000 

VanHool T2145 57-passenger motorcoach operated by Executive Coach Luxury 

Travel, Inc. (Executive Coach), transporting 33 members of the Bluffton University 

baseball team, the driver, and his wife, was traveling south on Interstate 75 

(I-75) in Atlanta, Georgia. The motorcoach had departed from the university, near 

Toledo, Ohio, about 7:00 p.m. the previous day and was en route to a competition 

in Sarasota, Florida. When the original driver had stopped in Adairsville, 

Georgia, approximately halfway through the 18-hour trip, the 65-year-old relief 

driver, accompanied by his wife, boarded the motorcoach and began driving at 

4:30 a.m. to complete the trip to Florida. The relief driver had driven approximately 

54 miles and, according to witnesses, was in the southbound high occupancy 

vehicle (HOV) lane at milepost 250 when the motorcoach departed the interstate, 

traveling at highway speed, onto the HOV-only left exit ramp to Northside Drive. 

(See figures 1 and 2.)

The exit ramp came to an end at the stop sign-controlled T-intersection 

with Northside Drive. As the motorcoach entered the intersection at an estimated 

speed of 50 to 60 mph, the driver steered to the right and then collided with 

the reinforced portland cement concrete bridge wall and chain-link security 

fence located along the southern edge of the eastbound lanes of the overpass. 

The vehicle overrode the bridge rail, rotated clockwise, and fell 19 feet onto the 

southbound lanes of the interstate. The motorcoach came to rest on its left side 

(driver’s side), perpendicular to the southbound lanes of I-75. Two southbound 

passenger vehicles received minor damage from debris as the motorcoach fell onto 

I-75; none of the passenger vehicle occupants were injured. Seven motorcoach 

occupants were killed: the driver, the driver’s wife, and five passengers. Seven 

other motorcoach passengers received serious injuries, and 21 passengers 

received minor injuries.
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Figure 1. Regional view of motorcoach route.
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Once inside the Atlanta beltway (Interstate 285), the driver used the HOV 

lane,1 which was to the left of the four southbound traffic lanes and separated 

from them by a double white line. Figure 3 shows the motorcoach’s travel route 

as it approached the Northside Drive exit (lower-right corner). The HOV-only 

left exit at Northside Drive is the first left exit encountered in the Atlanta area 

on southbound I-75, and it precedes the next left exit, the interstate merge, by 

1 mile. The motorcoach’s intended route of travel just past the accident location 

would have followed I-75 as it merged with Interstate 85 (I‐85) through downtown 

Atlanta.

1 HOV lanes are one of several types of managed lanes, often called preferential lanes, that restrict 

access based on vehicle class, limited access locations, number of vehicle occupants, or price (toll lanes). The 

I-75 HOV route used by the accident motorcoach was restricted to buses and two-person carpools.

Figure 2. Local route of accident motorcoach through Atlanta.
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Figure 4 shows the sequence of collisions in this accident. The motorcoach 

traveled up the 1,120-foot HOV-only left exit ramp at Northside Drive, through the 

elevated T-intersection, and collided with the reinforced portland cement concrete 

bridge wall and security fence located along the southern edge of the eastbound 

lanes of the overpass. While crossing the intersection at an estimated speed of 

50 to 60 mph, the driver steered to the right. The left-front corner of the motorcoach 

impacted the concrete bridge wall, and four passengers were ejected onto Northside 

Drive. The motorcoach overrode the bridge wall, rotated clockwise (270 degrees), 

and fell onto the interstate below, ejecting six passengers and partially ejecting two 

additional passengers onto I-75.

Figure 3. Path of the motorcoach as it approached the Northside Drive exit.
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The motorcoach came to rest on the driver’s side in a 90-degree rollover 

orientation, pointing east, and blocking the southbound lanes of I-75, as shown 

in figure 5. Two southbound passenger vehicles, a 2005 Chevrolet Equinox and 

a 2003 Ford F150 pickup truck, received minor damage after being hit by debris 

from the motorcoach as it fell from the overpass onto I-75; no passenger vehicle 

occupants were injured.

Figure 4. Photo illustration of the motorcoach accident sequence.
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Injuries

The accident motorcoach had 35 occupants: the driver, his wife, 28 

university students, and 5 university personnel. The motorcoach driver, his wife, 

and five passengers seated at the front of the motorcoach sustained fatal injuries. 

(See table 1.) 

Table 1. Injuries.

Injury type

Motorcoach 

driver

Motorcoach 

passengers Others Total

Fatal 1 6 0 7

Serious 0 7 0 7

Minor 0 21 0 21

None 0 0 0 0

Total 1 34 0 35

Title 49 Code of Federal Regulations (CFR) 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 an injury 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, or 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.

Figure 5. Accident scene with Northside Drive in the upper-left corner and the motorcoach at 

rest on I-75.
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The driver’s wife was seated in the jump seat2 to the right of the driver’s 

seat; both the driver and his wife were wearing two-point lap belt restraints. The 

five fatally injured passengers were in seats 3B, 4C, 6A, 6D, and 7B (see figure 6 

on the next page) and were not restrained. Of the 33 passengers (not counting 

the driver and his wife), 11 were asleep on the center aisle floor or on the floor 

between seats.

Twelve occupants were ejected from the motorcoach. Eleven of those 

passengers were seated in seats 1C, 2B, 2C, 3B, 3C, 4C, 6A, 6D, 7B, 7D, and 9A; the 

twelfth passenger was lying in the aisle between rows 3 and 4. Four passengers 

seated in the front of the motorcoach (seats 1C, 2B, 2C, and 3C) were ejected through 

the windshield3 or the left-front side windows onto Northside Drive before the 

motorcoach departed that roadway and fell onto I-75, landing on the driver’s side. 

Six passengers were ejected from left-side windows as the motorcoach impacted 

I-75. Two passengers were partially ejected and trapped between the motorcoach 

and the I-75 roadway (seats 7D and 9A).

The general nature of the injuries sustained by the motorcoach occupants 

was blunt force trauma. With the exception of the driver and his wife, the fatally 

injured passengers were propelled from their seats, causing them to sustain 

severe head, upper torso, and internal trauma. The driver and his wife, who were 

lap-belted, sustained fatal blunt force trauma injuries.

Once the motorcoach came to rest, 25 occupants remained within or partially 

within the motorcoach. Of these occupants, 12 passengers exited the motorcoach 

through the windshield opening, 6 passengers used the emergency roof hatch 

adjacent to row 11, and 3 passengers were assisted by first responders. The four 

remaining occupants—the motorcoach driver, his wife, and the two partially 

ejected passengers (seats 7D and 9A)—were extricated by Atlanta firefighters.

2 The jump seat is also referred to as the tour operator’s seat, but there was no tour operator on this 

trip.

3 In a postaccident interview, the passenger seated in seat 2B said that he was ejected through the 

windshield opening. No evidence exists to determine whether the three other passengers ejected onto 

Northside Drive went through the windshield or through the left-front side windows.
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Figure 6. Seating diagram.
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Emergency Response

At 5:38 a.m., city of Atlanta Communication Center dispatchers were 

notified of the accident through 9-1-1 and initiated emergency response by local 

public safety agencies. Emergency response was provided by the Atlanta–Fulton 

County Emergency Management Agency, the Atlanta Police Department Incident 

Command Center, and the Atlanta Fire Department. First responders arrived at 

5:43 a.m., 5 minutes after the accident occurred, followed by emergency medical 

service support from Grady Health Care Systems, Piedmont Hospital, and the 

Atlanta Medical Center.

The Grady Health Care Level 1 Trauma Center received 19 injured persons, 

Piedmont Hospital received 3 persons, and the Atlanta Medical Center received 

7 persons. These medical facilities were located within 5 miles of the accident site. 

The driver and five fatally injured passengers (including the driver’s wife) were 

taken to the Fulton County Medical Examiner’s Office. Another injured passenger 

died while at the Grady Health Care Trauma Center and was subsequently 

transported to the Medical Examiner’s Office.

Driver Information

Experience and Work History

The 65-year-old motorcoach driver possessed an Ohio Class B commercial 

driver’s license (CDL) with both passenger and school bus endorsements that was 

issued on November 30, 2004, to expire December 6, 2008. The driver’s medical 

certification, as required by 49 CFR 391.45, was issued on March 1, 2005, and had 

expired at midnight on March 1, 2007. At the time of the accident, the driver had 

not been medically certified within 24 months, as required by 49 CFR 391.45 (a).

The driver had 6 years of experience driving motorcoaches for Executive 

Coach part-time beginning in March 2001. He did not hold another job at the time 

of the accident. The driver had worked as a substitute school bus driver in Ohio 

for 4 1/2 years between September 2000 and February 2005. The school district 

provided an “excellent” preemployment reference to the motor carrier in March 

2001. The driver had no traffic violations in the prior 6-year period of motorcoach 

driving. He had been involved in an injury accident while operating an Executive 

Coach motorcoach on January 19, 2002, for which he was found not at fault. 

The accident occurred when the driver of a van turned left into the path of the 

motorcoach.

The driver had driven the same charter trip as the accident trip between Ohio 

and Florida on two previous occasions, in 2005 and 2006, both times transporting 

the Bluffton University athletes to a baseball tournament in Sarasota. According to 
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interviews with the motor carrier, Executive Coach planned the trip itinerary with 

the customer and each driver planned the route of travel, often using maps, Webbased sites, or travel club services.

Work/Rest Schedule

The motorcoach driver’s log indicated that he had been off duty for the 

12 days preceding the accident. On March 1, 2007, the day before the accident, 

the driver left Executive Coach’s business location in Ottawa, Ohio, driving 

a 15-passenger company van to pre-position himself as the relief driver for the 

next day’s trip. He and his wife departed at 9:00 a.m., traveled approximately 

550 miles and, according to hotel records, arrived in Adairsville, Georgia, at 

7:37 p.m. on March 1. The motorcoach driver’s logbook recorded an entry of 

“off duty” for the approximately 9 hours of driving time that day. The driver began 

the March 2 trip at 4:30 a.m. Table 2 shows the driver’s known activities 72 hours 

before the accident. Figure 7 shows the driver’s rest schedule.

Table 2. Driver’s preaccident activities.

Wednesday, February 28 Driver’s logs indicated he had been off duty for the 12-day period from 

February 17 through 28.

Thursday, March 1 Depart Ottawa, Ohio, at 9:00 a.m. in a company van.

Refuel van in Mt. Vernon, Kentucky, at 2:08 p.m. and again in Dalton, 

Georgia, at 6:18 p.m.

Check into hotel in Adairsville, Georgia, at 7:37 p.m.

Friday, March 2 Depart Adairsville, Georgia, about 4:30 a.m. Refuel motorcoach at 

4:40 a.m.

Accident occurred at 5:38 a.m.

Figure 7. Driver’s work/rest schedule.
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At the time of the accident, the driver was assigned a company cellular 

telephone owned by the motor carrier. The motorcoach also had a citizens band 

radio. The telephone was not recovered, but a passenger seated near the front 

reported that the driver was not using a telephone or the citizens band radio at the 

time of the accident. Based on cellular telephone records, Safety Board investigators 

confirmed that the company telephone had not been used for several days before 

the accident.

Medical and Pathological Information

The driver had a CDL medical certificate, issued on March 1, 2005,4 which 

was valid for 2 years; it expired the day before the accident. This certificate, Medical 

Examination Report for Commercial Driver Fitness, was signed by a chiropractor, 

and the two previous medical examination reports were signed by two different 

physicians.

According to the March 1, 2005, medical examination report, the driver was 

6 feet tall and weighed 225 pounds. His uncorrected vision was noted as 20/40, 

corrected to 20/13, requiring the use of corrective lenses. The medical examination 

report further stated that the driver was taking three medications (amlodipine, 

benazepril, and atenolol) to control high blood pressure; his blood pressure was 

reported as 146/82. The driver was also noted to be taking sertraline for the 

treatment of “nervousness.” Previous medical examination reports stated that the 

sertraline was being used for “depression” (March 9, 2003) and that the driver had 

also reported “loud snoring” (April 9, 2001). According to the driver’s medical 

records, he had been seen in October 2006 by a physical medicine and rehabilitation 

specialist, who noted that the driver complained of low back pain but indicated 

that the pain was not aggravated by driving. The specialist prescribed clonazepam, 

a drug sometimes used to treat anxiety.

On February 20, 2007, 10 days before his CDL medical certificate was due to 

expire, the driver had a preventative physical examination for Medicare with his 

primary care physician but did not get a CDL physical examination. The driver’s 

medications at that time included: sertraline, 100 mg; amlodipine, 5 mg; benazepril, 

20 mg; atenolol, 50 mg; clonazepam, 0.5 mg (at bedtime); and hydrocodone, 5 mg 

(at bedtime as needed). His depression was noted to be controlled on sertraline. 

According to the driver’s 2007 physical examination, he was 73 inches tall,5 weighed 

224 pounds, and had a blood pressure of 140/82.

An autopsy performed by the Fulton County Medical Examiner noted 

evidence of hypertensive cardiovascular disease, cardiomegaly (enlarged heart), 

and hepatomegaly (enlarged liver). The medical examiner determined the cause of 

death to be blunt force trauma of torso. Results from toxicology testing performed 

4 The most recent known past medical examination report dates were April 9, 2001; March 9, 2003; and 

March 1, 2005.

5 This height differs from the driver’s 2005 exam record of 6 feet, or 72 inches.
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by the Federal Aviation Administration’s Civil Aerospace Medical Institute (CAMI) 

laboratory identified only atenolol, sertraline (0.378 microgram/mL in blood), and 

ibuprofen in the driver’s blood and urine.

Vehicle Information

The 2000 VanHool model T2145 57-passenger motorcoach measured 45 feet 

5 inches long, 8 feet 6 inches wide, and 11 feet 10 1/2 inches tall. The wheelbase 

measured 23 feet 6 1/4 inches. Due to the condition of the motorcoach and the 

discharge of cargo during the accident, the total preaccident weight was estimated 

by calculation to be 43,826 pounds. According to the engine control module, the 

vehicle had traveled a total of 364,462 miles.

The accident motorcoach received an Ohio Public Utilities Commission 

Commercial Vehicle Safety Alliance (CVSA) “vehicle only” safety inspection on 

February 23, 2007, and no defects were noted. Maintenance documents dating 

from the time that the motorcoach was delivered new to Executive Coach on 

August 2, 2000, were reviewed, and no major repairs or recurring problems were 

documented.

The motorcoach was equipped with a six-wheel pneumatic disc braking 

system. In postaccident testing, the brake chambers activated the calipers on all 

brakes, with the exception of the left-front brake, which had a damaged brake 

chamber due to impact. Brake rotors were measured; the thickness for each of 

the six rotors was within minimum guidelines. The tires displayed no evidence 

of preaccident abnormalities. The motorcoach was also equipped with a 

Meritor/Wabco antilock braking system that included automatic traction control. 

According to VanHool documents, the minimum turning angle of the accident 

motorcoach was 51 degrees.

A Williams Controls, Inc., electronic accelerator pedal was found detached 

from its floor mounting in the driver’s foot well area. The electrical connector 

remained attached to the pedal, and postaccident testing showed it to perform 

within specified ranges. The adjacent brake pedal was found in a full downward 

position, with the forward wall of the foot well pressed against it. Three tire marks, 

found on the roadway at the top of the exit ramp, were from the left-front tire, a 

left-rear tire, and a right-side tire as the motorcoach made a sharp turn to the right. 

There were no skid marks before impact.

The accident motorcoach had cruise control. The dual switch system was 

found with the on/off switch in the “on” position, indicating that the system was 

available to the driver, but investigators could not determine whether the cruise 

control was active at the time of the accident. Only one headlamp bulb remained 

intact, and Safety Board metallurgical testing was inconclusive as to whether the 

high beams were illuminated at the time of the accident.
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The accident motorcoach was not equipped with a dedicated crash or event 

data recorder (EDR), though it was equipped with an electronically controlled 

Cummings diesel engine having a module capable of providing configuration 

and diagnostic information. The motorcoach was also equipped with an Intec 

backup camera system that did not have the capability to record video, images, 

or data. It also had a Scenic View forward-facing video camera that was mounted 

along the top of the windshield and connected to several video monitors. 

Postaccident examination determined that the forward-facing camera was part of a 

closed-circuit video system with no recording capabilities.

The motorcoach had a vertically divided lower windshield made of tinted 

safety glass that was laminated with an ultraviolet-ray blocking film and set in 

rubber. The upper windshield was laminated with ultraviolet-ray blocking bronze 

safety glass that was set in rubber. All side windows were made of tempered 

bronze safety glass;6 each side had five emergency push-out windows hinged at 

the top with two red emergency handles at the bottom. There were two emergency 

escape roof hatches.7

Only the driver’s seat, the jump seat, and the first row of the passenger seats 

were equipped with two-point lap belts; the other 53 seats were not equipped 

with seat belts. Further, the motorcoach was not equipped with airbags. Physical 

evidence showed that the driver and jump seat passenger were wearing their lap 

belts, but no evidence could be found showing that the available lap belts in the 

first row of passenger seats had been used. In the United States, motorcoaches are 

required to have an occupant protection system only for the driver, not for the 

passengers.8

Vehicle Damage

The motorcoach sustained the majority of damage to the left-front corner 

(driver’s side), left side, and left-rear corner (see figures 8 and 9), and there was 

interior deformation in the area of the driver’s station and front boarding door. 

The structural frame of the motorcoach was deformed, leaning toward the left. 

All of the windows along the left side were shattered; all of the windows along 

the right side remained intact, including the windows on and above the boarding 

door. Deformation of the motorcoach did not intrude into the passenger space.

6 Tempered glass has been processed by controlled thermal or chemical treatments to increase its 

strength. It breaks into small cube-shaped fragments instead of sharp glass shards.

7 Transpec A503016 and Transpec A503017.

8 Seat belts, required on passenger vehicles, are a common component of occupant protection systems. 

Another common design element of occupant protection, compartmentalization, is a passive system that 

requires no action on the part of the occupant. Compartmentalization on school buses is accomplished by 

having seats closely spaced in secure anchorage with cushions and seatbacks covered in energy-absorbing 

materials. The entire seat structure is designed to absorb energy and deform to dissipate the energy of the 

crash away from the passenger and into the surrounding environment.
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The engine compartment 

in the rear of the motorcoach 

was partially crushed, more so 

on the left side than the right, as 

shown in figure 9. The engine 

and transmission were displaced 

right and upward with the engine 

partially knocked off the engine 

mounts. The left steer axle tire 

and the left outside drive axle 

tire were both damaged and 

deflated.

The motorcoach seats 

showed interior impact damage 

from passengers who struck the 

seatbacks and armrests. Even 

though the initial impact was 

to the front of the motorcoach 

as it struck the Northside Drive 

bridge wall, the final impact as 

the motorcoach landed on I-75 

was to its rear. Twelve of the 57 

passenger seats were deformed 

aft,9 and there were broken or 

deformed armrests on 6 seats.

Accident Reconstruction

Using the physical 

evidence found by examining 

the vehicle and the roadway, the 

motorcoach’s motions during 

the accident were reconstructed. 

Physical evidence on the 

roadway included several feet 

of tire marks that began just 

before the intersection of the exit 

ramp with Northside Drive and continued until the motorcoach initially struck the 

reinforced concrete bridge wall and security fencing located along the southern 

edge of the eastbound lanes of the overpass. Accident reconstruction determined 

that, based on the radius of travel and lateral acceleration, the motorcoach’s speed 

9 The extent of seat deformation was as follows: seat 2B, 4 inches; seat 3C, 16 inches; seat 5A, 26 inches; 

seat 5B, 26 inches; seat 5D, 10 inches; seat 7A, 31 inches; seat 7B, 30 inches; seat 8D, 26 inches; seat 10D, 

28 inches; seat 11B, 31 inches; seat 13A, 22 inches; and seat 13B, 22 inches.

Figure 8. Accident motorcoach, front view.

Figure 9. Accident motorcoach, rear view showing 

engine compartment.
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as it entered the intersection was 50 to 60 mph,10 which is consistent with the 

statement of a witness who indicated that the motorcoach driver did not decelerate 

as he traveled up the exit ramp.11 This estimate is also consistent with the speed 

of 52 mph indicated on the speedometer of the motorcoach during postaccident 

examination.12 Another witness traveling in the right southbound lane of I-75, who 

had observed the motorcoach in front of him and to his left traveling up the ramp, 

estimated the motorcoach’s speed to be 65 mph.

The tire marks also confirm that just before entering the intersection, the 

driver steered to the right. Physical evidence at the accident site and from the 

vehicle showed that as the driver attempted to maneuver through the intersection, 

the left-front corner of the motorcoach struck the reinforced portland cement 

concrete bridge wall and security fencing. This collision caused the motorcoach 

to rotate clockwise, and as the vehicle moved forward, it struck the barrier 

again with its left-side/left-rear corner, mounted the barrier, and fell from the 

Northside Drive overpass onto the southbound lanes of the interstate below. The 

motorcoach landed with the left-rear corner leading, before coming to rest on its 

left side facing east.

Motor Carrier Operation

The accident motorcoach was owned and operated by Executive Coach 

Luxury Travel, Inc., headquartered in Ottawa, Ohio. The privately owned 

company, which had been in business since 1998, was sold following the accident 

and is no longer operating. According to its Federal Motor Carrier Safety 

Administration (FMCSA) registration, Executive Coach was an authorized, 

interstate for-hire passenger motor carrier. At the time of the accident, the 

company operated 6 motorcoaches in 10 States using 2 full-time drivers and 20 

part-time drivers.

Bluffton University had taken about 13 to 18 trips per year with Executive 

Coach since 2000. During postaccident discussions with the Bluffton University 

official responsible for transportation, Safety Board investigators learned that 

the university employees who had originally selected Executive Coach as a 

10 This estimate is based on a radius of travel of 318 feet (calculated using the center of gravity of the 

motocoach as it traveled over the tire marks) and a maximum lateral acceleration of 0.7 g. The Georgia 

Department of Transportation (GDOT) measured the dry friction of a car tire at 0.86 g and that factor was 

adjusted because the maximum friction for a motorcoach tire is approximately 80 percent of car tire friction. 

This estimate provides the vehicle speed as it traveled over the path indicated by the tire marks. Because the 

motorcoach would have slowed as it produced the tire marks, the vehicle speed at the beginning of the tire 

marks would have been slightly higher and the speed at impact with the barrier would have been slightly lower. 

Additionally, there is evidence that the brakes engaged just before the collision with the barrier, which would 

have slowed the motorcoach even more.

11 A motorist stopped on Northside Drive with an unobstructed view of the I-75 deceleration ramp estimated 

the speed to be 50 to 60 mph, noting that the motorcoach did not decelerate as it traveled up the ramp.

12 The postaccident speed indicated on a speedometer is not always a good indicator of a vehicle’s 

precollision speed. In this accident, the speed is corroborated by other physical evidence.
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transportation vendor in 2000 had left the university and that the criteria for 

their selection of Executive Coach were unknown. According to the university 

official, the decision to contract with Executive Coach for the March 2007 trip 

was based on past service and accommodation of the university’s transportation 

needs. Bluffton University officials were unaware that they could check the 

motor carrier’s safety record using the FMCSA’s Safety and Fitness Electronic 

Records (SAFER) system, which offers company safety data to industry and the 

public over the Internet. The SAFER system indicated that Executive Coach had 

a satisfactory rating.

The FMCSA’s Motor Carrier Management Information System (MCMIS)13

indicated that, in the 2 years from March 2005 to March 2007, Executive Coach had 

17 inspections: 12 level V inspections, 1 level III inspection, 3 level II inspections, 

and 1 level I inspection.14 The company received no out-of-service violations as a 

result of those inspections.

Federal commercial vehicle inspection regulations (49 CFR 396.17) require 

that commercial vehicles be inspected annually. The Ohio CVSA motorcoach 

inspection program qualifies as a substitute for the federally mandated program.15

Ohio’s February 23, 2007, inspection of the accident motorcoach found no defects. 

Further review of the FMCSA and Ohio records indicated that Executive Coach’s 

motorcoaches had been inspected annually since 1998 and had not shown any 

out-of-service violations based on mechanical defects.

The FMCSA conducted a compliance review of Executive Coach on 

January 31, 2001, for which the company received a satisfactory compliance 

rating. The company also received a satisfactory rating following the FMCSA’s 

postaccident compliance review on April 4, 2007. Operational deficiencies 

associated with nonrated regulations that did not affect the rating calculation were 

noted.16 All of the violations to nonrated elements were associated with driver, not 

vehicle, infractions.17

13 The MCMIS is a database of motor carrier census information, inspections, accidents, and enforcement 

history. Company profiles from MCMIS can be obtained by the general public for a fee.

14 North American inspection level categories include standard inspection (level I), walk around 

driver/vehicle (level II), driver only (level III), special (level IV), and vehicle only (level V).

15 Revised Ohio Code 4513.52 requires passenger-carrying vehicles to be inspected annually by May 31 

every year.

16 Violations to nonrated elements included the following: failure to ensure that random drug and alcohol 

tests are unannounced (382.305(k)(1)); using a driver not medically examined and certified during the 

preceding 24 months (391.45(b)(1)); failure to complete a record of duty status (395.8(e)); failure to require 

the driver to prepare a record of duty status in the prescribed form and manner (395.8 (f)); failure to obtain 

from a driver used for the first time or intermittently a signed statement providing total time on duty for the 

preceding 7 days and the time that driver was last relieved from duty (395.8(j)(2)); failure to ensure that driver 

vehicle inspection reports are complete and accurate (396.11(b)); and failure to ensure that the driver signs 

the vehicle inspection report when defects or deficiencies are noted (396.13(c)).

17 As a result of its investigation of the Wilmer, Texas, accident that occurred during the 2005 evacuation 

preceding Hurricane Rita, the Safety Board reiterated Safety Recommendation H-99-6 and issued a new 

recommendation (H-07-3) asking that the FMCSA change the current rating review process so that all violations 
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Federal regulations (49 CFR 391.51) require motor carriers to keep 

current records of their drivers’ qualifications to operate commercial vehicles. 

The investigation found no record of the accident driver’s having completed 

a qualifying medical examination effective for the timeframe beginning 

March 2, 2007. The FMCSA’s postaccident compliance review of Executive Coach 

identified a violation for using a driver not medically examined and certified 

during the preceding 24 months.

Federal regulations (49 CFR 395.8(f)) also require that drivers maintain 

a logbook during a trip and that the company maintain a file of the originals. 

A review of logbooks for the accident driver and the driver of the first leg of 

the accident trip contained no hours-of-service violations; however, the accident 

driver’s hours for the pre-positioning trip on March 1, 2007, were logged as 

“off duty” when they should have been logged as “on duty.” At the time of the 

accident, Executive Coach employed 22 drivers; all but two worked part-time. 

The company did not record work hours for drivers employed at other facilities, 

as required.

Executive Coach operated its own drug and alcohol testing program, 

administered by a health center in Ottawa, Ohio. In addition to preemployment 

testing, the company randomly tested 10 percent of drivers for alcohol and 

50 percent of drivers for drug use annually, in accordance with 49 CFR 382.305. The 

accident driver tested negative for drugs and alcohol during his preemployment 

test and on four subsequent random drug tests. Postaccident review of Executive 

Coach’s records determined that the company’s random drug testing was not 

always unannounced, as required.

The company had no formal in-service training program, no written 

policies on driver procedures, and no driver requirement to conduct pretrip 

safety briefings for passengers. The company did have requirements for 

driver-vehicle inspections,18 but recent compliance reviews indicated that 

post-trip inspections and inspection form sign-offs were not regularly completed. 

Drivers were invited, but not required, to attend quarterly company meetings. 

Drivers were generally given 30-day notice of assigned trips. Family members of 

drivers were permitted to ride with the driver on charter trips with the customer’s 

prior permission, as was the case during the accident trip.

of regulations (driver and vehicle) are reflected in calculating a carrier’s final rating. For further information, 

see National Transportation Safety Board, Motorcoach Fire on Interstate 45 During Hurricane Rita Evacuation, 

Near Wilmer, Texas, September 23, 2005, Highway Accident Report NTSB/HAR-07/01 (Washington, DC: 

NTSB: 2007).

18 In accordance with 49 CFR 392.7, 396.11, and 396.13.
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Meteorological Information

Data from the U.S. Naval Observatory indicated that on March 2, 2007, 

at 5:48 a.m. eastern standard time, the sun was 10 degrees below the horizon. It 

was dark and more than an hour before sunrise. Weather data, obtained from 

the Charley Brown Airport, 6 miles west of the accident site, indicated that the 

temperature was 47° F, with calm winds, 6 miles’ visibility, and overcast conditions 

at 15,000 feet. The roadway was dry.

Speed Study

Following the accident, on March 8, 2007, between 5:00 and 6:00 a.m., GDOT 

performed a speed study of the southbound lanes of I-75 in the vicinity of the 

accident. The 85th percentile speed for all southbound vehicles was 75 mph and 

the 50th percentile speed was 71 mph, with an average running speed of 70.3 mph. 

The posted speed limit in this area is 55 mph, and the design speed is 60 mph.19

Traffic Volume

The most recent data from GDOT20 showed the average daily southbound 

traffic count on I-75 near the accident location to be 95,920 vehicles per day. The 

southbound HOV lane carries an average of 6,800 vehicles per day, and the HOV 

exit ramp for Northside Drive carries an average of 500 vehicles per day.

Road Design

I-75 was originally constructed in the 1950s as a four-lane expressway 

with a raised median. In 1982, a widening and reconstruction project on I-75 from 

Northside Drive to Peachtree Creek21 included construction of interchange exit 

ramps and provisions for HOV lanes.22 Beginning in 1985, the exit ramps, designed 

as part of the HOV traffic plan, were operated as general purpose on- and off-exit 

ramps. In preparation for the 1996 Olympics,the I-75 HOV lanes were marked and 

activated.

19 Design speed is the maximum safe speed that can be maintained over a specified section of highway 

when conditions are so favorable that the design features of the highway govern. In the accident area, I-75 is 

functionally classified as a principal urban arterial freeway with a design speed of 60 mph to match the rolling 

topography and frequent changes in horizontal alignment.

20 The data cover 2006, the last full year before the accident.

21 GDOT project I-75-3 (139) 09, Fulton County, project no. 710451.

22 Applicable design guidelines included the following: 1967 American Association of State Highway and 

Transportation Officials (AASHTO) Policy on Design Standards—Interstate System; 1973 AASHTO Policy 

on Design of Urban Highways and Arterial Streets; 1979 FHWA Safety Evaluation of Priority Techniques for 

High-Occupancy Vehicles; and the 1978 Manual on Uniform Traffic Control Devices (MUTCD), revision 4.
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Atlanta currently has 90 HOV-lane miles with plans for more along the 

northwest corridor of Interstates 75 and 575. To minimize the hazard of lane 

changes and cross-freeway merging, major interchanges on such routes may be 

equipped with HOV‐only left exit ramps that are engineered into the existing 

urban infrastructure.

Left Exits

The I-75 exit for Northside Drive HOV traffic was on the left side of the 

roadway; the four general purpose traffic lanes had access to a right exit. HOV 

restrictions for this highway segment, which are full-time, limit lane use to vehicles 

with two or more passengers and buses. The HOV lane on this highway segment 

starts at Interstate 285 and continues approximately 7 miles south to the Northside 

Drive HOV exit, which is the first left exit encountered along the southbound I-75 

route. HOV markings along that route include 48 diamond pavement markings 

and 34 HOV diamonds on median-mounted or overhead signs. There are eight left 

HOV exits in the Atlanta metropolitan area.23

Design consistency is defined as the conformance of a highway’s geometric

and operational features with driver expectancy.24 According to National 

Cooperative Highway Research Program (NCHRP) Report 502,25 driver expectancy 

relates to the observable, measurable features of the driving environment that 

increase a driver’s readiness to perform a driving task in a particular manner. 

Geometric features of a roadway (such as curves, intersections, and shoulder 

widths) that are unexpected increase the risk of driver error. A lack of 

standardization in highway design violates driver expectancy.

Roadway Alignment

On the I-75 approach to Northside Drive, the road curves to the left for 

almost a half mile (2,268 feet), straightens for 750 feet, and then curves to the left 

again for 2,857 feet around a left-side retaining wall. The second curve begins 

413 feet before the HOV-only left exit ramp. The total increase in elevation for 

the 1,120-foot-long southbound Northside Drive HOV exit ramp is 19 feet. The 

23 Left HOV exits in the Atlanta metropolitan area occur at I-75 southbound at Spring Street; I-75 

southbound and northbound at C.W. Grant Parkway; I-75 northbound at Memorial Parkway; I-75 southbound at 

Piedmont Road; I-75 southbound at Akers Mill Road; I-85 northbound at Lindbergh Drive; and I-75 southbound 

at Northside Drive.

24 Most highway research attributes the concept to G.J. Alexander and H. Lunenfeld, Driver Expectancy 

in Highway Design and Traffic Operations (1986), according to U.S. Department of Transportation, Federal 

Highway Administration, Driver Expectancy in Highway Design and Traffic Operations, FHWA-TO-86-1 

(Washington, DC: FHWA, 1986).

25 Transportation Research Board (TRB), National Cooperative Highway Research Program, Geometric 

Design Consistency on High-Speed Rural Two Lane Roadways, NCHRP Report 502 (Washington, DC: TRB, 

2003) 1.
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elevation of the ramp is shown in figure 10. The vertical curve26 elevation of the 

roadway occurs approximately 475 feet past the exit gore,27 or approximately 

950 feet into the exit ramp. The exit ramp has no posted warning speed sign. 

According to GDOT engineers, a warning for a slower speed was unnecessary 

because interchange lighting mitigated the visibility limitation caused by the 

vertical curve.28

The Northside Drive exit ramp is a tapered departure lane (not a parallel 

lane), diverging gradually from the HOV interstate through lane and separated 

from it by a white dashed line. The distance from the beginning of the divergence 

to the area where the exit lane achieves its full width (12 feet) is 278 feet. The 

longitudinal distance of the lane split from the initial point of divergence to the 

beginning of the exit gore point is approximately 475 feet.

Lighting and Sight Distance

Stopping sight distance values may exceed pavement visibility distances 

afforded by low-beam headlights, regardless of whether the roadway profile is level 

or vertically curving. Following this accident, investigators measured a daytime 

sight distance of 885 feet from the southbound I-75 lane at the point where the 

overhead HOV exit sign can first be seen behind the longitudinal median barrier 

and the light standards.29 At the posted speed of 55 mph, this distance is traveled 

in 11 seconds. The sight distance for the exit gore point was 542 feet, a distance 

traveled in 6.7 seconds at 55 mph.

For nighttime driving, the I-75 HOV Northside Drive interchange has 

100‐foot‐tall high-mast lighting (see figure 11). The traffic lanes of I-75 have 

luminaries erected on the median barrier at 200-foot intervals. These light 

supports have dual-mast lights with a 50-foot mounting height. Safety Board 

investigators confirmed that all of the lighting was functional at the time of the 

accident.

26 The vertical alignment of a road consists of straight segments (leveled or inclined) connected by sag 

(concave) or crest (convex) vertical curves. Combinations of these elements create various road profiles.

27 The gore is defined as the area between the main roadway and the ramp, just beyond where the ramp 

branches from the main roadway.

28 MUTCD guidance for the use of speed reduction signs is based on engineering judgment (section 

2C.30).

29 GDOT calculated the 885-foot sight distance by using a bus driver’s eye height of 7.5 feet.
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Exit ramp elevation. Figure 10.
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I-75 and I-85 HOV Merge

Less than 1 mile south of 

the Northside Drive exit, I-75 

approaches Atlanta from the 

northwest and merges with I-85, 

which approaches Atlanta from 

the northeast. The traffic pattern 

for this merge separates the 

southbound I-75 HOV lane from 

the four southbound general 

purpose travel lanes. The single 

HOV lane diverges to the left to 

align with the northbound traffic 

lanes as they pass under I-85 

in preparation for the merge. 

Figure 12 shows the route 

configuration for the interstate 

merge. Figure 13 shows the 

roadway view of the southbound 

I-75 HOV lane separation before 

the merge.

Accident Location History

During the course of this 

investigation, GDOT provided 

a 10-year history (1997 to 2007) 

of traffic accidents for the 

Northside Drive exit. (See 

appendix B.) GDOT was unable 

to provide an accident history 

for this exit from 1985 through 

1996, when it was operated as 

an exit ramp for general traffic 

instead of an HOV-only left exit 

ramp.

Of the nine accidents that occurred from 1997 through 2007 (including this 

accident), seven involved injuries; of those seven accidents, three involved fatal 

injuries. Six of the nine accidents involved a single vehicle, and all but one of those 

six accidents occurred at night. The drivers ranged from 51 to 76 years old; none 

were residents of Atlanta, and only two were residents of Georgia. Seven of the nine 

accidents shown in appendix B involved drivers who had taken the exit ramp at 

Figure 11. Exit ramp showing high-mast lighting 

(circled).

Figure 12. Southbound I-75 separation of HOV-only 

lane.
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interstate speeds and had failed to stop at the intersection stop sign and subsequently 

collided with the curb, the concrete bridge wall, or another vehicle.

Following this motorcoach accident, six other drivers who had reportedly 

driven the accident route contacted the Safety Board to express concern that the 

signage and pavement markings were confusing. Two of those drivers reported 

that they had inadvertently exited onto Northside Drive when it was their intention 

to follow I-75. One of those callers was a CDL driver of a motorcoach.

Traffic Control Devices and Guidance

Traffic control devices provide regulatory, warning, and route guidance 

information to drivers. These devices include traffic signal lights, signs, and 

roadway markings. The national standard for all traffic control devices is the 

Manual on Uniform Traffic Control Devices.

30

Title 23 CFR Part 655 provides the States with a 2-year period from the 

effective date to adopt the MUTCD. By December 22, 2005, States were required 

30 The MUTCD was first published in 1935. Since then, there have been eight editions, some 

with extensive revisions. The most recent edition was published in November 2003 (U.S. Department of 

Transportation, Federal Highway Administration, Manual on Uniform Traffic Control Devices for Streets and 

Highways, [Washington, DC: FHWA, 2003]). An electronic version of the 2003 MUTCD, including revisions 1 

and 2, is the most current version <http://mutcd.fhwa.dot.gov>.

Figure 13. I-75 HOV lane diverging to the left in preparation for I-85 merge.
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to have adopted the 2003 edition of the MUTCD or to have a State MUTCD or 

supplement that is in substantial conformance with it.31 One role of the Federal 

Highway Administration (FHWA) Division Offices is to review and approve any 

State MUTCD or supplement (23 CFR 655.603(b)). Georgia is one of 24 States that 

have adopted the 2003 MUTCD without a State supplement. The 2003 MUTCD is 

scheduled for revision in 2008, and a notice of proposed amendments (NPA) to the 

MUTCD was published in the Federal Register on January 2, 2008.32

The 1988 MUTCD would have been in effect when the Northside Drive exit 

was changed to an HOV-only exit before the 1996 Olympics. GDOT’s conversion 

of existing I-75 traffic lanes to HOV lanes33 involved signing, pavement marking, 

milling, and inlay work.34 At that time, the MUTCD (section 2B‐20) contained 

slightly more than a page of text on HOV signage and markings, including six 

exemplar signs. It contained no traffic control device guidance for the merge of 

two urban HOV interstate lanes.

The current (2003) MUTCD provides additional information and 

requirements regarding preferential lane35 signs. The MUTCD “standard”36

requires that preferential lanes use signs and pavement markings to advise road 

users of their status and that specific signs be used exclusively with HOV lanes to 

indicate occupancy requirements and time restrictions (MUTCD, section 2B.26, 

figure 2B-7). The MUTCD requires that ground-mounted preferential lane signs, 

when used, be located adjacent to the preferential lane and that overhead signs be 

mounted directly over the lane. A related standard describes pavement markings, 

including the use of the diamond symbol. The only information specific to HOV 

sign placement is a guidance statement that notes sign placement “should be 

determined by engineering judgment based on prevailing speed, block length, 

distance from adjacent intersections, and other considerations.”

The MUTCD organizes signs by purpose and uses a standard color scheme 

(section 1A.12 and table 2A-4). Regulatory signs, which have black, white, or 

31 Compliance dates are deadlines by which States must have brought their traffic control devices into 

conformance with specific provisions of the MUTCD. These compliance dates generally range from 5 to 15 

years from the effective date of the MUTCD final rule.

32 “National Standards for Traffic Control Devices; the Manual on Uniform Traffic Control Devices for 

Streets and Highways; Revision”; Federal Register, Vol. 73, No. 1 (January 2, 2008).

33 GDOT project CM-OOMS (2) Ct.1; Clayton, Fulton, Cobb, and Dekalb counties; project no. 71297.

34 Applicable design guidelines included the following: 1991 AASHTO Policy on Design Standards—

Interstate System; 1990 AASHTO Policy on Geometric Design of Highways and Streets; and 1992 AASHTO 

Guide for the Design of High-Occupancy Vehicle Facilities.

35 Preferential lanes are designated for special traffic uses such as HOV, light rail, buses, taxis, or 

bicycles.

36 MUTCD headings are used to classify the nature of the text. Standards are statements of required, 

mandatory, or specifically prohibitive practice regarding a traffic control device. Guidance is a statement 

of recommended, but not mandatory, practice in typical situations; deviations are allowed if engineering 

judgment or an engineering study indicates that the deviation would be appropriate. Standards and guidance 

are sometimes modified by Options, which serve as a statement of practice that is a permissive condition. 

Support provides supplemental information.
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red legends on black, white, or red backgrounds (section 2A.11), inform drivers 

of selected traffic laws or regulations; examples include speed limit signs, stop 

signs, or preferential lane signs (MUTCD, chapter 2B). Guide signs show route 

destinations, directions, and distances (MUTCD chapter 2E, addresses guide 

signs for interstates). Guide sign color combinations depend on the type of route 

and sign function but generally have white legends on green backgrounds.

The other left exit ramps along southbound I-75 terminate at 

traffic-signalized intersections. In deciding whether traffic signals should be 

used at an intersection, the current MUTCD (chapter 4C, “Traffic Control Signal 

Needs Study”) requires that traffic volume, flow patterns, pedestrian flow, school 

zones, sight distances, and accident rates be evaluated. According to MUTCD 

section 4C.08, an intersection can be identified as a high-accident location if, 

“five or more reported crashes, of types susceptible to correction by a traffic 

control signal, have occurred within a 12-month period.” GDOT concluded that 

this location did not warrant a traffic control signal.

Signage and Pavement Markings Approaching Accident Location

Guide Signs for I-75 HOV Traffic

Interchange guide signs in proper sequence should provide the driver 

with the necessary information for route navigation. There are two overhead 

advance route guide signs37 on I-75 for Northside Drive: NORTHSIDE DRIVE, 

EXIT 1 MILE at mile marker 252.6 and NORTHSIDE DRIVE, EXIT 1/2 MILE

at mile marker 252.1. (See figures 14 and 15.) Both signs have black lettering 

on white backgrounds with a white-on-black HOV diamond to the left and a 

BUSES/CARPOOLS ONLY supplemental plaque on the bottom. Both signs are 

posted directly over the HOV lane and occur before the I-75 overpass for Howell 

Mill Road. In accordance with the 2003 MUTCD (sections 2E.33 and 2E.34), a 

third exit directional sign, NORTHSIDE DRIVE, with a left arrow, is mounted 

over the exit lane on a support post located on the median barrier;38 and a fourth 

exit sign is posted to the right of the exit lane in the exit gore. (See figures 16 and 

17.) The advance guide signs contained no indication of a left exit, and none of 

the signs included a LEFT plaque.

37 Advance guide signs give notice well in advance of the exit point of the principal destinations served 

by the next interchange and the distance to that interchange (2003 MUTCD, section 2E.30).

38 The MUTCD standard for this sign states that it should carry the exit number, if used; route number; 

cardinal direction; and destination, when appropriate. The overhead guide sign did not display the word 

“EXIT.”
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Figure 14. Advance guide sign (EXIT 1 MILE) for Northside Drive exit.

Figure 15. Advance guide sign (EXIT 1/2 MILE) for Northside Drive exit.
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Figure 16. Overhead directional sign for Northside Drive.

Figure 17. Northside Drive exit sign in gore area.
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GDOT’s original (1985) signage and pavement marking plan39 called for 

dual signs posted side by side: one for the Northside Drive HOV-only left exit 

(arrow sign) and one pull-through sign40 guiding the HOV traffic on southbound 

I-75.According to section 2E.11 of the MUTCD,

Pull-through signs should be used where the geometrics of a given 

interchange are such that it is not clear to the road user which is the through 

roadway, or where additional route guidance is desired. Pull-through signs 

with a down arrow should be used where the alignment of the through 

lane is curved.

The design for placement of the signs was changed in August 1995. Because 

of structural failures in the base plate bolts on type II cantilevered dual-sign 

structures, GDOT had adopted a policy to eliminate them. To support dual signs 

(both an exit sign and a pull-through sign), a sign support over the entire roadway 

would have been needed. GDOT indicated that a sign support over the entire 

roadway would limit sight distance to other signs ahead. GDOT’s design change 

was partially documented in interdepartmental memorandums reviewed during 

the course of the Safety Board’s investigation. GDOT’s solution was to separate the 

two signs, placing the HOV-only left exit sign in its original location and moving 

the I-75 HOV South pull-through sign 0.2 mile north, mounted to the Howell Mill 

Road overpass. Figure 18 shows the Northside Drive exit sign separated from the 

I-75 pull-through sign, and figure 19 shows the original design plan positions for 

the signs mounted side-by-side.

Stop Signs at the Northside Drive Intersection

Closer to the accident location, approximately 300 feet from the intersection 

STOP sign, were two STOP AHEAD signs (MUTCD W3-1a), one on each side of 

the exit ramp. Both STOP AHEAD signs had supplemental plates indicating that 

the intersection stop sign was 300 feet ahead. Additional STOP AHEAD pavement 

markings were located on the roadway. Figure 17 shows the driver’s view of both 

the pavement markings and the STOP AHEAD signs at the top of the exit ramp. 

The intersection STOP sign, which measured 36 by 36 inches, was posted on the 

right side of the road at Northside Drive.

The accident motorcoach traveled up the exit ramp at highway speeds (50 

to 60 mph). When the motorcoach reached the STOP AHEAD signs, which are 

located 300 feet in advance of the intersection, it would have required 225 to 266 

feet, assuming maximum braking, to stop. That distance would have been traveled 

in 1.0 to 1.5 seconds.

39 GDOT project CM-OOMS (2) Ct. 1; Clayton, Fulton, Cobb, and Dekalb counties; project no. 712970. 

The signage and pavement marking plan was approved by the FHWA and was in compliance with the MUTCD 

guidance in effect at the time.

40 A pull-through sign is an overhead lane-use sign intended for through traffic.
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Figure 18. Pull-through sign for the I-75 HOV lane positioned at the Howell Mill Road overpass 

instead of mounted next to the Northside Drive exit sign.
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Pavement Markings

The 2003 MUTCD standard (section 3B.22) calls for preferential lanes to 

be marked with an appropriate diamond pavement symbol or message, such 

as the diamond symbol for an HOV lane, spaced at regular intervals based on 

the prevailing traffic speed. For the southbound I-75 HOV lane, these diamond 

markings occurred approximately every 1/6 mile. The FHWA recommended in 

an August 2007 information memorandum to Division Administrators,41

in addition to the regular spacing interval, that the appropriate pavement 

marking be placed along preferential lanes at strategic locations, such as 

at major decision points, direct exit ramp departures, and along access 

openings with adjoining general-purpose lanes.

The Northside Drive HOV-only exit ramp contains the diamond symbol 

immediately past the exit gore point. A diamond symbol is also located in the 

HOV through lane immediately past the exit gore point.

Edge lines, which separate a travel lane from an adjacent shoulder, are 

always solid (MUTCD, section 3B.06). Along a one-way roadway that is one-half 

of a divided highway, such as I-75, yellow edge lines mark the left edge of the 

roadway and serve as a boundary between a travel lane and the left shoulder; 

41 FHWA information memorandum on traffic controls devices for preferential lane facilities, Associate 

Director for Operations, August 3, 2007, page 3.

Figure 19. Northside Drive exit sign and pull-through sign for the I-75 HOV lane mounted side by 

side.
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white edge lines mark the right edge of the roadway and serve as a boundary 

between a travel lane and the right shoulder. The general purpose lanes for I-75 

are separated by spaced white pavement stripes; the HOV lanes are delineated 

from the general purpose lanes by solid double white pavement markings.42 At the 

time of the accident, the Northside Drive exit was marked with a white dashed line 

marking the tapered exit deceleration lane, as shown in figure 20, to distinguish 

the HOV-only left exit ramp from the through lane.43 The exit gore area was striped 

with 10-inch white lane edge marking lines. It was not marked with channelizing 

lines to define the neutral area or to direct exiting traffic in accordance with the 

2003 MUTCD (section 3B.05).

The FHWA advised in its August 2007 information memorandum to 

Division Administrators that when extra emphasis is needed to differentiate 

between exit and travel lanes, a legend pavement marking EXIT or EXIT ONLY 

should be considered for use in the parallel or tapered deceleration lane for the 

direct exit and/or on the direct exit ramp itself just beyond the exit gore. At the 

time of the accident, the Northside Drive exit ramp was not marked with EXIT

pavement markings.

42 Solid double lines become dashed double lines at periodic intervals to allow for conventional traffic to 

transition to HOV lanes.

43 The MUTCD, section 3B-11, provides for the optional extension of the pavement line with dotted 

pavement marking at exit ramps.

Figure 20. Exit roadway markings at Northside Drive.
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Postaccident Traffic Control Device Changes

Following this accident, GDOT enhanced the signage at the intersection by 

increasing the STOP sign dimensions from 36 to 48 inches. A second STOP sign was 

added to the left of the exit ramp terminus, and a flashing beacon was mounted 

to the top of the STOP sign located on the right side of the exit ramp terminus. 

A raised concrete traffic island with reflective pavement markers was added to 

the exit ramp terminus. A Large Double Arrow warning sign (MUTCD W1‐7), 

measuring 60 by 30 inches, was placed across Northside Drive on the concrete 

bridge wall across from the end of the ramp to provide additional warning that 

the ramp ended. A second set of STOP AHEAD reflective pavement markings was 

added midway up the exit ramp, and the STOP AHEAD sign’s size was increased 

to 60 inches. Roadway pavement markings were repainted to 10 inches wide, 

a dashed yellow line was used to replace the white dashed pavement marking 

across the exit split,44 and a reflective pavement marking EXIT was added after the 

HOV diamond at the beginning of the ramp.

In its August 2007 information memorandum to Division Administrators, 

the FHWA acknowledged the significant variation in the application of design 

principles for traffic control devices when applied to preferential lane facilities. 

The memorandum stated that the FHWA wished to “encourage uniformity among 

such devices by expediting conformance with the requirements of the MUTCD.” 

With regard to HOV left exits, the FHWA recommended that an additional plaque 

with the legend LEFT in black on a yellow background be placed at the top left 

edge of any guide sign calling for a left direct exit maneuver. The FHWA also 

recommended the use of dotted white pavement line markings across a direct exit 

taper to separate an exit lane from a continuing through lane.

44 The MUTCD standard for longitudinal markings of preferential lanes (section 3B.23) calls for yellow 

lines to delineate the left edge of the roadway. To separate concurrent flow traffic, such as at an exit, a single 

broken white line indicates that crossing is permitted.
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Analysis

This analysis first discusses the factors and conditions that the Safety Board 

has excluded as neither causing nor contributing to the accident. It then provides 

a brief overview of accident events and discusses the safety issues relevant to 

the accident: inadequate HOV traffic control devices, inadequate motor carrier 

driver oversight, lack of EDRs on motorcoaches, and lack of motorcoach occupant 

protection.

Exclusions

The weather was clear and dry at the time of the accident. Motor carrier 

and motorcoach records indicated that the vehicle was well maintained and in 

proper working condition; it had passed a Federal commercial vehicle inspection 

conducted by Ohio CVSA inspectors just 1 week before the accident. Postaccident 

inspection of the motorcoach showed no defects or anomalies. The Safety Board 

concludes that neither the weather nor the mechanical condition of the vehicle 

caused or contributed to the accident.

The driver had been a part-time motorcoach driver for 6 years and, before 

that, had been a school bus driver. During his employment with Executive Coach, 

he had no traffic violations, although he had been involved in one accident in 

which he was found not at fault. The Safety Board therefore concludes that the 

driver’s qualifications and driving record were not factors in this accident.

Postaccident testing of the driver’s blood and urine was negative for alcohol 

and illicit drugs. At the time of a physician’s visit 10 days before the accident, the 

driver’s medical records indicated that he had a prescription for hydrocodone, a 

narcotic pain reliever. However, the substance was not detected in the postaccident 

toxicology evaluation, indicating that it had not been used in the previous 

24 hours. The Safety Board concludes that the driver was not impaired by alcohol, 

illicit drugs, or narcotic pain medication.

Appropriate resources were dispatched, and first responders were at the 

accident scene within 5 minutes of the accident. Medical services from three local 

area hospitals were coordinated to handle the treatment of the injured. The Safety 

Board therefore concludes that the emergency response was timely and effective.
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Accident Discussion

The accident motorcoach was traveling from Bluffton University in 

Bluffton, Ohio, to Sarasota, Florida, a trip of approximately 1,120 miles. Except 

for local travel at each end, the trip followed I-75 South through the States of 

Ohio, Kentucky, Tennessee, Georgia, and Florida. As it approaches Atlanta 

from the northwest, I-75 merges with I-85 from the northeast; both interstates 

have HOV traffic lanes that merge through the metropolitan Atlanta area. Upon 

entering the metropolitan area southbound on I-75, drivers encounter the first 

HOV-only left exit, Northside Drive. One mile past the Northside Drive HOV 

exit, the merge of I-75 with I-85 is constructed such that the southbound I-75 

HOV lane diverges to the left, separating from the general purpose travel lanes, 

and curves around to connect with the southbound I-85 HOV traffic lane much 

like an exit ramp. This merge of the HOV lanes and the general purpose traffic 

lanes is handled separately. The accident driver intended to take I-75 and merge 

with I-85 to continue south. The I-75 HOV route for that merge diverged from the 

HOV lane to the left at an angle similar to the Northside Drive left HOV exit.

The motor carrier stated that the driver was responsible for pretrip 

planning. Based on pretrip planning, map reference, and two previous trips 

through Atlanta, the driver likely expected the I-75 HOV-only traffic lane to 

diverge to the left from the general purpose through traffic lanes for the interstate 

merge with I-85. Without a clear indication of the Northside Drive exit ramp’s 

relative position to the interstate through lane, the driver could have mistaken 

the Northside Drive HOV-only left exit ramp for the high-speed ramp between 

interstates (I-75 and I-85). This situation is made even more likely because of the 

infrequent use of left exits; Northside Drive is one of only seven in the Atlanta 

area.

In the weeks following the accident, other drivers who had experienced 

problems navigating the I-75 HOV-only left exit ramp at the accident location 

contacted Safety Board investigators. One, a professional motorcoach driver, had 

mistakenly taken the exit ramp and run the stop sign on Northside Drive at the 

top of the ramp but was able to negotiate a right turn and stop the motorcoach. 

He explained that he had unintentionally followed the solid yellow edge line on 

the left up the exit ramp.

If the accident driver was expecting the left ramp to connect I-75 HOV 

traffic with I-85 HOV traffic, he may also have focused on the solid yellow line 

on the left side of the HOV lane as a cue for following that route. Given the dark 

travel conditions and the limited sight distance of the exit ramp as the highway 

curved behind the retaining wall, this driver may have narrowed his attention to 

follow the yellow edge line as a salient navigational cue.

Left interstate exits are an uncommon road design. GDOT records 

identified several similar accidents that had occurred at this location that should 

have alerted GDOT to the need for additional driver guidance. Seven of the nine 
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accidents documented by GDOT in the accident vicinity involved drivers who 

had taken the exit ramp at interstate speeds and failed to stop at the intersection. 

Following fatal accidents in 2001 and 2002, GDOT conducted a review of the 

intersection traffic control devices at Northside Drive. The Northside Drive 

intersection did not meet the accident experience criteria or other MUTCD 

warrants and, therefore, signals were not installed. GDOT’s postaccident safety 

evaluations did not consider whether remediating traffic control devices were 

needed before the required stop. Consequently, the Safety Board concludes that 

GDOT failed to identify the Northside Drive HOV-only left exit, which was 

in a left curve preceding a high-speed left interstate merge, as an unexpected 

arrangement that required additional traffic control devices to guide road 

users.

The primary issue under investigation in this accident was the adequacy 

of the highway signage and roadway markings to reliably alert drivers of the 

HOV-only left exit ramp and to provide route guidance for interstate through 

traffic. First, the driver inadvertently and unknowingly exited the interstate; and 

second, once on the HOV-only left exit ramp, he received insufficient cues to alert 

him that he was no longer on the interstate. By the time the driver realized the 

route mistake, he had insufficient time to stop the motorcoach at the Northside 

Drive intersection. The following section describes the specific roadway design 

elements and traffic control devices that influenced the motorcoach driver’s route 

decisions and collision avoidance behavior.

Inadequate Signage at Northside Drive Exit

The original signage plan for I-75 included a pull-through sign mounted 

adjacent to the exit sign; this pair of signs is shown in figure 18. But, according 

to GDOT, the pull-through sign was installed 0.2 mile north of the Howell Mill 

Road overpass (so that the southbound accident driver encountered it earlier 

than the exit sign) because of installation problems with the dual cantilevered 

structure. An alternative to the cantilevered sign structure would have been a 

full overhead structure45 capable of holding both the exit sign and the interstate 

pull-through sign. GDOT did not use that solution, however, stating that the 

addition of a pull-through sign would have limited the sight distance for the 

signs mounted on the Northside Drive overpass. The overpass signage consists 

of two periodically recurring HOV-lane use message signs (BUSES/CARPOOLS 

ONLY) and an advance route guide sign for three general purpose traffic exits 

that occur after the upcoming interstate merge in 1.25 miles. A sight distance of 

more than 1,120 feet (the length of the exit ramp) is more than adequate for these 

general signs, and, in fact, is a greater sight distance than that afforded users of 

the Northside Drive exit sign (based on a sight distance of 875 feet).

45 GDOT refers to this sign support as a Type V sign structure.
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Guidance provided by the FHWA after the accident46 states that the 

pull-through sign is of particular importance when the direct exit could be mistaken 

for a preferential lane that continues, as occurs on curved alignments or where 

other physical roadway features, such as an overpass, make it difficult to discern 

the exit geometry from the approach. Positioning the exit sign to the left of the 

pull-through sign in a side-by-side configuration would have alerted road users 

of the lane positions; separated, the pull-through and exit signs lost their spatial 

relationship. Further, removing the pull-through sign from the location where the 

original design plans called for it to be mounted also removed it from the decision 

point on the highway where it was most needed. Moreover, the information on the 

Northside Drive overpass signs that GDOT was concerned about obscuring was 

not critical to immediate route guidance. The Safety Board therefore concludes 

that GDOT, in changing the original design plan by separating the Northside 

Drive HOV exit sign from the I-75 South pull-through sign, caused the effective 

meaning of the paired signs to be lost at a critical decision point on the highway. 

The Safety Board also concludes that positioning the Northside Drive HOV-only 

left exit direction sign next to the I-75 South pull-through sign will promote positive 

guidance to motorists on the appropriate travel lanes at a critical decision point on 

the highway.

The southbound I-75 HOV lane starts at the Interstate 285 beltway 

approximately 7 miles north of the Northside Drive exit. Along that route, the 

accident driver would have encountered 48 HOV diamond pavement markers 

and experienced 34 HOV diamonds on median-mounted or overhead signs. The 

Northside Drive exit ramp also displayed an HOV diamond pavement marking 

just past the exit gore, and the exit gore sign displayed an HOV diamond with 

an arrow. The exit ramp design at Northside Drive was unconventional and 

problematic, most notably because it was the first left exit along the route and, 

as such, was unexpected. The Safety Board therefore concludes that, because 

of the unique combination of geometric features and lane restrictions of an 

HOV-only left exit, redesigning the Northside Drive exit signs to include a 

message plaque with the legend LEFT in black on a yellow background placed at 

the top left edge of the 1 MILE and 1/2 MILE guide signs will better alert drivers 

to the unconventional exit design. The Safety Board believes that GDOT should 

install a LEFT message plaque on the 1 MILE and the 1/2 MILE advance exit guide 

signs and on the directional arrow exit sign for Northside Drive and position the 

pull-through sign for the southbound I-75 HOV through lane so that it is next 

to the Northside Drive left-exit direction sign. To ensure that other left exits are 

readily recognized by motorists, the Safety Board also believes that GDOT should 

install exit signs with LEFT message plaques for left interstate exits. The Safety 

Board further believes that GDOT should install pull-through signs next to the exit 

direction (arrow) signs to ensure positive route guidance at exits with limited sight 

distance, short ramps, or multiple route choices. The Safety Board also believes 

that, to ensure that these signage conventions are applied consistently throughout 

the Nation’s interstate highway system, the FHWA should include in an MUTCD 

46 FHWA Associate Director for Operations, August 3, 2007, page 2.
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standard the requirements for HOV-only left exits to have LEFT message plaques 

on all exit guide signs and for exit direction (arrow) signs to be positioned next to 

pull-through signs at exits with limited sight distance, short ramps, or multiple 

route choices.

In addition, the Northside Drive exit ramp had no advisory speed sign 

(MUTCD W13‐2) to advise the driver of a slower speed, despite the ramp’s 

relatively short length of 1,120 feet. Such signage would seem particularly relevant 

along a route where, based on the postaccident speed study, traffic exceeds the 

posted speed limit. A sign advising motorists of a lower exit ramp speed offers 

yet another opportunity to assist drivers in safely navigating the elevated ramp, 

particularly at night when sight distances are restricted. The Safety Board could 

not reliably determine whether the motorcoach headlamps were on high or low 

beam, but it is likely that the accident driver, like many travelers in urban traffic, 

would have been traveling with low-beam illumination. On a lighted roadway 

under those conditions, a vehicle’s headlights would illuminate the elevated 

roadway, but only after some distance up the ramp would they illuminate the 

STOP AHEAD pavement markings or the STOP sign, at which point, the accident 

motorcoach was within a few hundred feet of the intersection and still traveling 

at highway speeds (50 to 60 mph). This situation afforded the driver only 

1 to 2 seconds to perceive the sign message, understand its meaning, make a 

decision, and execute that decision. According to the MUTCD, this reaction time 

can vary from several seconds for general warning signs to 6 seconds or more for 

warning signs requiring a high degree of road user judgment. A reduced speed 

advisory sign early in the exit ramp would have indicated a different traffic situation 

to the driver and, if he had slowed, would have afforded him more time to process 

the stop sign information and execute a stop. The Safety Board concludes that 

because the Northside Drive exit ramp is short and terminates at a nonsignalized 

intersection, an advisory ramp speed sign is needed for motorist safety. The 

Safety Board believes that GDOT should install an advisory speed limit sign 

(MUTCD W13-2) on the Northside Drive HOV exit ramp and on interstate left exit 

ramps throughout the State. The FHWA’s recent NPA also addresses advisory exit 

speed signs, proposing in the section titled “Advisory Exit and Ramp Speed Signs” 

to revise the MUTCD standard to require the use of advisory speed limit signs on 

interstate ramps. The Safety Board agrees with the proposal and believes that the 

FHWA should include in an MUTCD standard criteria for the use of advisory 

speed limit signs for all interstate exit ramps.

Inadequate Pavement Markings at Northside Drive Exit

The driver’s intended route of travel was the southbound I-75 HOV lane 

and, given his speed of 50 to 60 mph, it is apparent that his movement to the exit 

ramp was a mistake. Because the driver likely did not realize that the motorcoach 

was on the exit ramp, he also did not realize the need to stop at the top of the 

ramp. His first visual cue for the ramp was the dashed white edge line separating 

the ramp from the HOV lane. A reliance on the yellow edge line that had guided 
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him through the long and gradual left curve of I-75 may have diminished his 

awareness of the dashed white line and also have contributed to his missing 

the barrier-mounted EXIT sign on the right in the gore area. Since the accident, 

GDOT has changed the dashed white line to a dashed yellow line; however, no 

MUTCD standard provides for the use of a dashed yellow line to delineate left 

exits. The MUTCD’s standard notes that yellow longitudinal markings delineate 

the separation of traffic traveling in opposite directions, the left edge of divided 

roadways, and the separation of two-way left turn lanes. The FHWA’s information 

memorandum regarding traffic control devices for preferential lane control sent 

to Division Administrators after the accident recommended that a dashed white 

guide line marking be used to separate an exit lane from a continuing through 

preferential lane; the guidance did not specifically address left exits.

Because yellow lines mark the left edge of divided roadways, and because 

dashed lines indicate an option for traffic crossing, GDOT used a yellow dashed 

line for postaccident marking on the Northside Drive exit ramp divergence from 

the interstate through lane. Although there is not specific guidance for that action, 

GDOT’s efforts to more positively mark the exit ramp merit consideration. If 

the driver was using the yellow edge line as his primary lane tracking cue, he 

might have been more likely to notice the dashed yellow marking delineating the 

exit. The Safety Board concludes that the use of yellow dashed lines for left exit 

pavement markings and white dashed lines for right exit pavement markings 

should be considered to emphasize and distinguish left exits. The Safety Board 

believes that the FHWA should evaluate the MUTCD standard for guide line 

marking requirements for interstate left exits.

Both the exit ramp and the I-75 HOV through lane contain an HOV diamond 

roadway pavement marking just past the start of the exit. The driver would have 

experienced a regular display of these HOV diamond pavement markings along his 

interstate route, and the exit ramp diamond pavement markings appeared identical 

to the I-75 HOV through lane markings. Further, the exit lane did not have an EXIT

pavement marking. After the accident, GDOT added an EXIT pavement marking 

to the Northside Drive exit ramp’s diamond pavement marking. The Safety Board 

agrees that this modification enhances the lane markings and helps to ensure that 

motorists realize they are exiting the interstate. The Safety Board concludes that 

pairing an EXIT pavement marking with the HOV diamond pavement marking 

is a useful traffic control enhancement for all left HOV exits. The Safety Board 

therefore believes that GDOT should add an EXIT pavement marking paired with 

the HOV diamond pavement marking at all left HOV interstate exits.

HOV Traffic Control Devices

Route guidance signs for HOV motorists traveling on I-75 South used the 

regulatory sign color convention of a black legend on a white background (see 

figures 14 through 17). Although this convention is appropriate to communicate 
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the HOV information for preferential lane use (buses and two-person carpools), 

motorists are accustomed to looking for a sign with a white legend on a green 

background for route guidance. Current managed lane facilities are split between 

those that use green guide signs and those that favor regulatory signs with 

white as their primary background color.47 Developing a national consistency of 

terminology, color, and symbology for managed lanes is the FHWA’s number 

one priority on its 2007 prioritized research list. The Safety Board agrees that this 

issue should be a priority. Consistency is the main factor in driver expectation, and 

driver expectancies for traffic control devices are based on previous experience of 

similar traffic situations. The Safety Board concludes that this accident illustrates 

the importance of HOV traffic control devices being sufficiently similar, regardless 

of their geographic location, to create consistent expectations related to common 

geometric, operational, and route characteristics.

The FHWA relies on a volunteer organization of professionals, the 

National Committee on Uniform Traffic Control Devices, to develop and revise 

the MUTCD. In 2003, the FHWA committed to an update cycle of 5 years, 

indicating that the next edition will be released in 2008. The comment period for 

the MUTCD NPA48 closed on July 31, 2008. The Safety Board believes that the 

FHWA should work with the National Committee on Uniform Traffic Control 

Devices to ensure that the next edition of the MUTCD is issued as scheduled in 

2008 and that the revision comprehensively addresses the uniformity of HOV 

traffic control devices, including left exits.

In the MUTCD NPA, the FHWA is proposing a standard to require 

black-on-yellow LEFT message plaques for left exits and advance guide signs, with 

a phase-in period of 10 years for existing signs. Although 10 years is a common 

phase‐in compliance period for new sign requirements, because the message 

plaques would be added to the top left edge of existing left exit signs and, in most 

cases, would not involve replacing existing signs in good condition, the Safety 

Board concludes that the supplemental LEFT message plaques should be phased 

in sooner than the typical 10‐year MUTCD compliance timeframe. Therefore, the 

Safety Board believes that the FHWA should require a phase-in period of 5 years 

for supplemental LEFT message plaques in the standard proposed for the next 

edition of the MUTCD.

Driver’s Medical Condition

The driver had several risk factors for obstructive sleep apnea: he was 

overweight, had previously reported snoring, and was on medications for the 

treatment of high blood pressure and anxiety. Although it is possible that the driver 

had some level of sleep apnea that prevented him from getting a restful night’s 

47 S. Chrysler and B. Kuhn, Traveler Information and Traffic Control Devices for Managed Lanes (College 

Station, Texas: Texas Transportation Institute, April 2007).

48 Federal Register, Vol. 73, No. 1 (January 2, 2008).
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sleep, the Safety Board was unable to find evidence for that conclusion. Despite 

his risk factors for the disorder, he had never undergone a medical evaluation for 

sleep apnea.

Following a 12-day period of being off duty, the driver drove 10.5 hours 

the day before the accident. He was off duty for nearly 9 hours (from 7:37 p.m. 

on March 1, 2007, until 4:30 a.m. on March 2), thereby meeting the regulatory 

requirements for being off duty for 8 hours. Based on previous investigations,49 the 

Safety Board has determined that the most important measures in predicting whether 

a driver will have a fatigue-related accident are (1) the duration of the last sleep 

period, (2) the total hours of sleep obtained in the 24 hours preceding the accident, 

and (3) whether a split sleep/work pattern was followed. However, none of these 

conditions applied to this driver; he had the opportunity to receive 7 to 8 hours sleep 

the night before the accident, he was not following a split sleep/work pattern, and 

he had only been driving for approximately an hour when the accident occurred. 

These factors, combined with the fact that the driver was maintaining control of 

the vehicle as it followed the exit ramp lane, indicate that he was not operating the 

vehicle asleep. The Safety Board concludes that the investigation found no evidence 

of the driver being asleep or otherwise incapacitated prior to the accident.

The driver was taking sertraline to control depression. The medication was 

found in his blood at a level many times than would be expected with the dose 

that he was prescribed, but near the level expected with the maximal dose of the 

substance.50 Controlled studies of the medication have not shown any significant 

sedation or interference with psychomotor performance at recommended doses, 

and the medication appears to improve performance in depressed patients.51 The 

driver was also prescribed clonazepam at bedtime to assist with sleep, but it is not 

clear when he might have taken the medication. The medication was not detected 

in the driver’s blood, but therapeutic concentrations are considerably below the 

levels typically reported by the CAMI toxicology laboratory.52 Clonazepam has 

been shown to impair cognitive and psychomotor tasks for at least 2 hours in the 

dose prescribed for the driver.53 Though it seems unlikely that the driver would 

have taken the medication within a few hours of the time of the accident, it cannot 

be completely excluded that the driver may have been impaired by the use of 

clonazepam.

49 National Transportation Safety Board, Factors That Affect Fatigue in Heavy Truck Accidents, NTSB 

Safety Study NTSB/SS-95/01 (Washington, DC: NTSB, 1995).

50 Based on data in R.C. Baselt, Disposition of Toxic Drugs and Chemicals in Man, 5th ed. (Foster City, 

California: Chemical Toxicology Institute, 2000).

51 See, for example: (a) W. Bondareff, M. Alpert, A.J. Friedhoff, E.M. Richter, C.M. Clary, and E. Batzar, 

“Comparison of Sertraline and Nortriptyline in the Treatment of Major Depressive Disorder in Late Life,” 

American Journal of Psychiatry Vol. 157, No. 5 (May 2000): 729-36 and (b) M. Siepmann, J. Grossmann, 

M. Muck-Weymann, and W. Kirch, “Effects of Sertraline on Autonomic and Cognitive Functions In Healthy 

Volunteers,” Psychopharmacology Vol. 168, No. 3 (2003): 293-8.

52 Baselt, Disposition of Toxic Drugs and Chemicals in Man.

53 J.D. Wildin, B.J. Pleuvry, G.E. Mawer, T. Onon, and L. Millington, “Respiratory and Sedative Effects 

of Clobazam and Clonazepam In Volunteers,” British Journal of Clinical Pharmacology Vol. 29, No. 2 

(February 1990): 169-77.
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Medical Certification

The driver did not possess a valid medical certificate at the time of the 

accident, but there is no evidence that the State or the motor carrier knew the 

driver would be operating the accident trip with an invalid medical certificate. 

It is also unclear whether the driver was aware that his medical certificate had 

expired 1 day before the accident trip. Being out of compliance by a matter 

of hours provides no indication of the driver’s medical condition, but it does 

mean that the driver was not medically examined and certified according to 

49 CFR 391.45. Executive Coach was responsible for ensuring that only medically 

qualified drivers were operating commercial vehicles in interstate commerce 

(49 CFR 391.41) and for having a copy of the current medical examiner’s certificate 

in its driver qualification files (49 CFR 391.51).

The driver visited his primary care provider 10 days before the accident, but 

no record could be found that he had completed a medically qualifying exam at 

that time. He had used three different providers to complete his last three medical 

certification examinations, and it is possible that he completed such an exam but 

had not provided the motor carrier with a copy of a certificate or report obtained. 

No current mechanism exists for the tracking of such examinations.

The Safety Board’s Most Wanted List of Transportation Safety 

Improvements includes the prevention of medically unqualified drivers from 

operating commercial vehicles. Safety Recommendations H-01-17 through -24,54

issued as a result of the Safety Board’s investigation of a 1999 motorcoach accident 

in New Orleans,55 address Federal medical oversight of commercial drivers.56 The 

two safety recommendations that are relevant to this accident—H-01-18, which 

covers the establishment of a tracking mechanism for exams performed, and 

H‐01‐20, which covers the provision of specific guidance for examiners—are both 

classified “Open—Unacceptable Response.” The Safety Board is aware that the 

FMCSA recently addressed the issue of guidance on obstructive sleep apnea at 

a Medical Review Board meeting in Salt Lake City in January 2008. The Medical 

Review Board recommended screening guidelines for the disorder, which the 

FMCSA is now considering. The Safety Board’s recommendations on the medical 

certification process of commercial vehicle drivers address all aspects of an 

appropriate, comprehensive program, and the Safety Board is closely following 

the FMCSA’s work to develop such a program.

54 Only three of these eight recommendations are currently in “Acceptable” status: H-01-19, on 

updating medical certification regulations, and H-01-22 and -23, on the enforcement of medical certificate 

requirements.

55 National Transportation Safety Board, Motorcoach Run-Off-The-Road Accident, New Orleans, 

Louisiana, May 9, 1999, Highway Accident Report NTSB/HAR-01/01 (Washington, DC: NTSB, 2001).

56 For more information, see <http://www.ntsb.gov/recs/mostwanted/medical_certification.htm>.
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Motor Carrier Driver Oversight

The accident driver failed to properly record hours-of-service information 

for the trip from Ohio to Georgia, and the investigation revealed that Executive 

Coach did not track the work hours of part-time drivers employed by other 

companies. Further, on April 4, 2007, the FMCSA conducted a postaccident safety 

assessment of Executive Coach. Although the carrier received a satisfactory rating, 

several regulatory requirements were not being met. Driver-related violations 

included the following: failure to ensure that random drug and alcohol tests were 

unannounced (382.305(k)(1)); using a driver not medically examined and certified 

during the preceding 24 months (391.45(b)(1)); failure to complete a record of duty 

status (395.8(e)); failure to require the driver to prepare a record of duty status in 

the prescribed form and manner (395.8 (f)); failure to obtain from a driver used for 

the first time or intermittently a signed statement providing total time on duty the 

preceding 7 days and the time last relieved from duty (395.8(j)(2)); failure to ensure 

that driver vehicle inspection reports are complete and accurate (396.11(b)); and 

failure to ensure that the driver signs the vehicle inspection report when defects 

or deficiencies are noted (396.13(c)). This lax record-keeping, along with the fact 

that Executive Coach was unaware that the accident driver would be operating 

the trip with an expired medical certificate, leads the Safety Board to conclude that 

Executive Coach inadequately monitored its drivers to determine their compliance 

with the Federal Motor Carrier Safety Regulations related to motorcoach operation.

As a result of its 1999 special investigation on motorcoach issues,57 the Safety 

Board asked the FMCSA to change its safety fitness rating methodology so that 

either adverse vehicle or driver performance alone is sufficient to result in an overall 

unsatisfactory rating of the carrier (H-99-6). The status of that recommendation 

is currently “Open—Acceptable Response,” and the issue remains on the Safety 

Board’s Most Wanted List. In its 2005 response to the Safety Board regarding 

that recommendation, the FMCSA described its Comprehensive Safety Analysis 

2010 (CSA 2010) initiative and plans for further rulemaking action regarding 

performance-based safety fitness procedures. Subsequent to that response, the 

Safety Board has had numerous briefings concerning the progress of CSA 2010. 

As recently as February 2008, the Safety Board received a status briefing from the 

FMCSA on its progress with CSA 2010, which provided an overview of a prototype 

system that targets unsafe practices and measures driver and carrier performance. 

According to the FMCSA, CSA 2010 contains both carrier and driver components 

and will result in a performance-based operational model for determining 

motor carrier safety. The agency began limited testing of the CSA 2010 program 

in 2008.58

57 National Transportation Safety Board, Selective Motorcoach Issues, Special Investigation Report 

NTSB/SIR-99/01 (Washington, DC: NTSB, 1999).

58 Three of the seven behavioral analysis and safety improvement categories and eight of nine 

interventions will be tested in four States: Colorado, Georgia, Missouri, and New Jersey.
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In its December 2007 report,59 the Government Accountability Office (GAO) 

reviewed the framework that the FMCSA has developed for managing and testing 

CSA 2010 and concluded that it is reasonable. According to the GAO report, the 

FMCSA expects to implement the carrier safety measurement system by 2010 

but does not anticipate the testing and deployment of CSA 2010’s driver safety 

measurement system and interventions to occur until after 2010.

As a result of its investigation of the Wilmer, Texas, accident during the 

evacuation of Hurricane Rita,60 the Safety Board reiterated Safety Recommendation 

H-99-6 and issued a new recommendation as follows:

H-07-3

To protect the traveling public until completion of the Comprehensive 

Safety Analysis 2010 Initiative, immediately issue an Interim Rule to include 

all Federal Motor Carrier Safety Regulations in the current compliance review 

process so that all violations of regulations are reflected in the calculation 

of a carrier’s final rating.

The current status of Safety Recommendation H-07-3 is “Open—Initial 

Response Received”; the FMCSA’s response to this recommendation is currently 

being evaluated by the Safety Board. The FMCSA’s postaccident compliance 

review rating for Executive Coach provides further evidence that a change in the 

assessment of motor carrier safety fitness methodology is warranted.

Event Data Recorders

An EDR is a device or function that records a vehicle’s dynamic, time-series 

data just before a crash (vehicle speed versus time) or during a crash (change 

in velocity versus time). Intended for retrieval after the crash event, EDR data 

can provide critical safety system performance information.61 To enhance crash 

testing with real-world data, it is important that data from motorcoach crashes 

be used for postaccident analysis, forensics, and design evaluation. At a recent 

SAE International (SAE) symposium on highway EDRs,62 industry representatives 

presented the status of standards work, current system operating experience, and 

evidence that many operators currently use vehicle data recorders to improve 

59 U.S. Government Accountability Office, Motor Carrier Safety: The Federal Motor Carrier Safety 

Administration Has Developed a Reasonable Framework for Managing and Testing Its Comprehensive Safety 

Analysis 2010 Initiative, GAO-08-242R (Washington, DC: GAO, December 2007).

60 NTSB/HAR-07/01.

61 The Safety Board’s 1999 bus crashworthiness special investigation identifies minimum vehicle 

parameters for recording. For more information, see National Transportation Safety Board, Bus Crashworthiness 

Issues, Highway Special Investigation Report NTSB/SIR-99/04 (Washington, DC: NTSB, 1999) 66.

62 Highway Vehicle Event Data Recorder Symposium, September 5-6, 2007 (Ashburn, Virginia: 

SAE International).
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operational control, to support insurance rates and claims, and to respond to 

litigation.

It is unfortunate that the Atlanta accident motorcoach was not equipped 

with any level of technology to provide vital precrash data. Lack of valuable crash 

data continues to restrict accident investigations; for example, in this accident, data 

concerning the exact vehicle speed, status of the cruise control and high beams, 

throttle position, and driver steering and brake inputs, as well as several other 

parameters, could not be precisely determined based on physical evidence. The 

Safety Board’s investigation into the cause of passenger injuries and the points of 

ejection was severely limited because insufficient data were available from which 

to calculate reliable crash pulses.63 An EDR would have provided vehicle dynamics 

information throughout the accident sequence. Crash pulses and/or Delta V 

are often used to calculate passenger occupant kinematics, help evaluate injury 

exposure, and help evaluate passenger protection safety devices and systems. 

Using these data, investigators can predict potential injury mechanisms and the 

effects of various design elements on occupant protection systems.

Although crash forces can sometimes be estimated by comparing the 

accident vehicle’s physical damage to instrumented crash test data, this method 

is not always reliable—particularly when crash test data are substantially limited, 

as they are for motorcoaches, and when the accident involves a barrier collision 

or a collision with a hard paved surface. The ability to estimate crash pulses was 

also limited by the fact that some surfaces of the motorcoach may have undergone 

multiple collisions. The Safety Board concludes that information on the acceleration 

time history (or crash pulses) critical to the evaluation of vehicle performance 

and occupant protection systems was unavailable to accident investigators and 

researchers because of the motorcoach’s lack of an EDR.

As a result of its 1996 safety study on child restraint systems64 and subsequent 

1997 air bag forum,65 the Safety Board recommended that the National Highway 

Traffic Safety Administration (NHTSA) address the on-board recording of crash 

data.66 About that time, the National Aeronautics and Space Administration 

and the Jet Propulsion Laboratory also recommended that NHTSA study the 

feasibility of installing and obtaining crash data for safety analysis from crash 

recorders on vehicles. In response, NHTSA organized the EDR Working Group, 

63 The term crash pulse, as used here, refers to the acceleration versus time history. It may be more 

helpful to think in terms of “crash forces” because the forces a vehicle is subjected to as a result of a collision 

are a direct function of the crash pulse.

64 National Transportation Safety Board, The Performance and Use of Child Restraint Systems, Seatbelts, 

and Air Bags for Children in Passenger Vehicles, Safety Study NTSB/SS-96/01 (Washington, DC: NTSB, 

1996).

65 National Transportation Safety Board, Proceedings of the National Transportation Safety Board Public 

Forum on Air Bags and Child Passenger Safety, Report of Proceedings NTSB/RP-97/01 (Washington, DC: 

NTSB, 1997).

66 Safety Recommendation H-97-21 asked that automobile manufacturers develop and implement a plan 

to gather better information on crash pulses and other crash parameters in actual crashes, utilizing current or 

augmented crash sensing and recording devices.
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which first met in October 1998. In 1999, the Safety Board held a symposium on 

transportation recorders.67 Later that year, as a result of its special investigation 

on bus crashworthiness,68 the Safety Board made the following two EDR-related 

recommendations to NHTSA:

H-99-53

Require that all school buses and motorcoaches manufactured after 

January 1, 2003, be equipped with on-board recording systems 

that record vehicle parameters, including, at a minimum, lateral 

acceleration, longitudinal acceleration, vertical acceleration, heading, 

vehicle speed, engine speed, driver’s seat belt status, braking input, 

steering input, gear selection, turn signal status (left/right), brake 

light status (on/off), head/tail light status (on/off), passenger door 

status (open/closed), emergency door status (open/closed), hazard 

light status (on/off), brake system status (normal/warning), and 

flashing red light status (on/off) (school buses only). For those 

buses so equipped, the following should also be recorded: status of 

additional seat belts, airbag deployment criteria, airbag deployment 

time, and airbag deployment energy. The on-board recording system 

should record data at a sampling rate that is sufficient to define 

vehicle dynamics and should be capable of preserving data in the 

event of a vehicle crash or an electrical power loss. In addition, the 

on-board recording system should be mounted to the bus body, not 

the chassis, to ensure that the data necessary for defining bus body 

motion are recorded.

H-99-54

Develop and implement, in cooperation with other Government 

agencies and industry, standards for on-board recording of bus 

crash data that address, at a minimum, parameters to be recorded, 

data sampling rates, duration of recording, interface configurations, 

data storage format, incorporation of fleet management tools, fluid 

immersion survivability, impact shock survivability, crush and 

penetration survivability, fire survivability, independent power 

supply, and ability to accommodate future requirements and 

technological advances.

In October 2000, NHTSA organized the Truck and Bus Event Data Recorder 

Working Group to focus on data elements, survivability, and event definitions 

related to trucks, school buses, and motorcoaches. The group’s results and findings 

67 National Transportation Safety Board, Proceedings: International Symposium on Transportation 

Recorders, May 3-5, 1999, Report of Proceedings NTSB/RP-99/01 (Washington, DC: NTSB, 1999).

68 NTSB/SIR-99/04.
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were published in May 2002.69 In 2004, the NCHRP completed a project that 

examined current U.S. and international methods and practices for the collection, 

retrieval, archiving, and analysis of EDR data for roadside and vehicle safety.70

Both the IEEE71 and SAE have published voluntary industry motor vehicle EDR 

standards.72 A second SAE standards committee, J2728—Commercial Vehicle 

Event Data Recorders, is specifically addressing data elements for medium- and 

heavy-duty trucks.73 Industry initiatives in standards development include

the American Trucking Associations Technology and Maintenance Council’s 

publication of a recommended practice to define the collection of event-related 

data on board commercial vehicles. The recommended practice outlines data 

elements, storage methodology, and retrieval approach for event data recording 

on commercial vehicles.

In the meantime, the FMCSA’s “Commercial Vehicle Safety Technology 

Diagnostics and Performance Enhancement Program” (also known as the “CV 

Sensor Study”) has worked to define driver and vehicle assistance products 

and systems and, in particular, advanced sensor and signal processors in trucks 

and tractor-trailers, with an emphasis on on-board diagnostic and improved 

safety-related products. The program involves developing EDR requirements 

for the analysis of accident data from the FMCSA’s Large Truck Crash Causation 

Study, with the goal of developing EDR functional specifications for both complete 

accident reconstruction and crash analyses. To date, this project has developed 

requirements for EDR components, hardware, software, sensors, and databases 

and has completed a cost-effectiveness analysis.74

In recent years, NHTSA has made progress in developing EDR data 

standards for light vehicles, which include passenger cars, multipurpose 

passenger vehicles, light trucks, and vans with a gross vehicle weight rating of 

3,855 kilograms (8,500 pounds) or less.75 In August 2006, NHTSA published a final 

69 National Highway Traffic Safety Administration, Event Data Recorders, Summary of Findings by the 

NHTSA EDR Working Group, Vol. II--Supplemental Findings for Trucks, Motorcoaches, and School Buses,

DOT HS 809 432 (Washington, DC: NHTSA, 2002).

70 H.C. Gabler, D.J. Gabauer, H.L. Newell, and M.E. O’Neill, Use of Event Data Recorder Technology 

for Highway Crash Data Analysis, NCHRP Project 17-24: Contractor’s Final Report (Washington, DC: TRB, 

2004).

71 Formerly the Institute of Electrical and Electronics Engineers, Inc., the organization is now known 

exclusively by the acronym IEEE.

72 IEEE Standard 1616-2004, IEEE Standard for Motor Vehicle Event Data Recorders (February 2005), 

and SAE Recommended Practice J1698-1, Vehicle Event Data Recorder Interface—Output Data Format

(December 2003).

73 Safety Recommendation H-02-35 called for the IEEE to develop on-board recorder standards that 

include time-stamped brake and transmission electronic fault codes using a recognized clock synchronized 

with other on-board EDR devices.

74 See FHWA IVI Program 134, “Development of Requirements and Functional Specifications for 

Event Data Recorders,” <http://www.itsdocs.fhwa.dot.gov/JPODOCS/REPTS_TE/14146.htm>, accessed 

April 3, 2008.

75 See Event Data Recorders—Final Rule, 49 CFR Part 563, NHTSA docket no. 25666, August 28, 2006. 

The rule includes qualifications for an unloaded vehicle weight of 2,495 kg (5,500 pounds or less), with the 
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rule that standardizes the information EDRs collect, making EDR data retrieval 

easier, and that addresses the survivability requirements for EDRs based on 

crash testing.76 The final rule was amended on January 14, 2008, in response to 

numerous petitions for reconsideration. Based on this revised rule, compliance 

dates have been changed to September 1, 2012, for most light vehicles, and to 

September 1, 2013, for vehicles manufactured in two or more stages. The new 

rule, however, does not address vehicles over 8,500 pounds and thus would not 

apply to buses or motorcoaches.

In its August 2007 “Approach to Motorcoach Safety,”77 NHTSA included 

a discussion of EDRs, stating that the agency has recently defined mandatory 

data elements for the voluntary installation of EDRs in light passenger vehicles. 

However, crash characteristics and relevant measurements for motorcoaches are 

different, as supported by the 2001 NHTSA EDR Working Group final report’s 

“Summary of Findings”:78

given the differing nature of cars, vans, SUVs [sport utility vehicles] and 

other lightweight vehicles, compared to heavy trucks, school buses, and 

motorcoaches, different EDR systems may be required to meet the needs 

of each vehicle class.

The EDR Working Group’s final report also noted the following:

• EDRs can improve highway safety for all vehicle classes by providing 

more accurate data for accident reconstructions, and

• U.S. and European studies have shown that the number and severity 

of crashes is reduced when drivers know that an on-board EDR is in 

operation.

However, NHTSA’s “Approach to Motorcoach Safety” also makes the 

seemingly contradictory statement that Safety Recommendations H-99-53 and -54 

concerning EDRs do not specifically relate to changes that would have a direct or 

quantifiable safety benefit for motorcoach occupants.79 The Safety Board disagrees; 

the lack of useful event data associated with accident motorcoaches represents 

a missed opportunity to better understand crash forces, ejection dynamics, and 

crashworthiness. The Safety Board concludes that EDRs would provide the 

accurate and detailed event data necessary to better understand crash causation 

and to establish design requirements for motorcoach crashworthiness and 

exception of walk-in type vans or vehicles that are designated to be sold exclusively to the U.S. Postal 

Service.

76 The rule includes standards for 45 EDR data elements: 15 standard data elements and 30 extra data 

elements for advanced EDRs.

77 National Highway Traffic Safety Administration, “Approach to Motorcoach Safety,” NHTSA docket 

no. 2007-28793-0001, page 20.

78 NHTSA docket no. 1999-5218-0009, page xi.

79 NHTSA docket no. 2007-28793-0001, page 20.
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occupant protection systems. The need for such information is particularly 

significant as EDRs become more widely used in the truck and transit industry, as 

evidenced at the September 2007 EDR symposium sponsored by SAE.80 During the 

symposium, representatives from industry noted that EDR applications are being 

more widely used for motor carrier analysis of accidents and to support more 

accurate insurance underwriting and risk analysis.

Also in its “Approach to Motorcoach Safety,” NHTSA states “Upon 

completion of SAE J2728, consideration of a requirement for heavy vehicle 

EDR installation into motorcoaches would be appropriate.”81 The Safety Board 

recognizes NHTSA’s progress in developing EDR standards for light vehicles. 

As a result of NHTSA’s work to date, Safety Recommendations H-99-53 and -54 

are currently classified “Open—Acceptable Response.” However, this accident 

again clearly illustrates the importance of this issue for heavy vehicles. The Safety 

Board therefore concludes that establishing EDR performance standards for 

motorcoaches and buses is necessary for the timely and efficient implementation 

of EDRs, which will, in turn, provide the data needed to develop effective 

occupant protection systems. The Safety Board urges NHTSA to actively push to 

complete standards work and, based on the development of standards for large 

motorcoaches, to require EDRs on all new motorcoaches. The Safety Board 

therefore reiterates Safety Recommendations H-99-53 and -54.

Survival Aspects and Motorcoach Occupant Protection

Of the 35 motorcoach occupants in this accident, 7 were killed, including the 

driver and his wife, both of whom wore lap belt restraints. The other five fatally 

injured occupants were ejected from the motorcoach. Five additional occupants 

were ejected and two more occupants were partially ejected.

From 2000 through 2006,82 43 motorcoach accidents occurred in which 

at least one occupant was fatally injured. In these motorcoach accidents, which 

resulted in 122 total fatalities (17 fatalities per year), 41 occupants were partially 

or fully ejected from the motorcoach (34 percent). In 15 of the 43 accidents 

(35 percent), the motorcoach rolled over; 38 of the 41 ejected fatalities (93 percent) 

occurred during rollover accidents. Similar analyses of occupant injury data can 

be found in studies conducted by other countries.83

80 Highway Vehicle Event Data Recorder Symposium, September 5 through 6, 2007, Ashburn, Virginia, 

SAE International.

81 Approach to Motorcoach Safety, NHTSA docket no. 2007-28791, page 21.

82 The Safety Board’s analysis of Fatality Analysis Reporting System data involved motorcoaches defined 

as a cross-country/intercity bus type or buses with no specific body type having a gross vehicle weight rating 

of 26,000 pounds or greater that are being used in scheduled service, commuter service, or as charter, tour, 

or shuttle buses.

83 M. Matolcsy, “The Severity of Bus Rollover Accidents,” Proceedings: 20th International Technical 

Conference on the Enhanced Safety of Vehicles, Lyon, France, June 18 through 21, 2007, Paper No. 07-0989 

(2007). See <http://www-nrd.nhtsa.dot.gov/pdf/nrd-01/esv/esv20/07-0152-O.pdf>, accessed April 3, 2007.
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The Federal Motor Vehicle Safety Standards contain 22 standards on 

crashworthiness. Most of these standards exempt motorcoaches with 

a gross vehicle weight over 10,000 pounds, and no Federal regulations 

require that motorcoaches in the United States be equipped with an 

occupant protection system. Although motorcoaches must comply with 

Federal Motor Vehicle Safety Standard (FMVSS) 217, which establishes 

minimum requirements for motorcoach window retention and release, and 

 FMVSS 302, which establishes standards for the flammability of interior materials,84

they do not have to comply with the host of other FMVSS occupant protection 

standards that apply to school buses85 and passenger cars.

A well-designed vehicle will manage the energy of a crash through its 

structure and minimize the energy transfer to passengers through an occupant 

protection system, which functions to retain the passengers within the seating 

compartment throughout the accident sequence and minimize the risk of injury. One 

example of an occupant protection system, known as “compartmentalization,”86

has been studied, tested, and required in school buses but not in motorcoaches.

Occupant Protection Initiatives

In 1994, the European Commission initiated a project to improve safety by 

fitting seat belts on motorcoaches.87 That study found that passenger ejection is 

a major cause of death and injury and that, although seat belts can significantly 

reduce or prevent passenger ejection, the whole system—seats, seat belts, and all 

anchorages—must be considered to ensure effectiveness. A more recent European 

Union (EU) study, by TNO-Automotive in the Netherlands,88 concluded that 

wearing either a lap or a lap/shoulder belt89 is safer than not wearing a seat belt 

and that the main advantage of wearing seat belts in a motorcoach is to prevent 

ejection during rollover accidents, as well as during frontal accidents.

84 FMVSS 208, Occupant Crash Protection; FMVSS 209, Seat Belt Assemblies; and FMVSS 210, Seat 

Belt Assembly Anchorages presently apply to the driver’s seat only.

85 49 U.S.C. §30125 defines a school bus as any vehicle that is designed for carrying a driver 

and more than 10 passengers and which, as NHTSA determines, is likely to be “used significantly” to 

transport “preprimary, primary, and secondary” students to or from school or related events (which include 

school-sponsored field trips and athletic events). This definition was enacted in 1974, as part of a comprehensive 

effort by Congress to enhance school bus safety.

86 Compartmentalization is an occupant protection system using closely spaced seats that have 

energy-absorbing seatbacks to create a protective envelope for the occupant.

87 D. Kecman and others, “Study of the Technical Requirements for Fitment of Seat Belts on Minibuses 

and Coaches,” Cranfield Impact Centre Report to European Commission, DGIII, Contract No. ETD/94/B5–

3000/MI/05 (1994-1995).

88 C.G. Huijskens, M. Schrooten, and P. de Coo, “Frontal Occupant Safety Simulation for Coach and 

Bus Passengers,” Proceedings: 18th International Technical Conference on the Enhanced Safety of Vehicles, 

Nagoya, Japan, May 19 through 22, 2003, Paper No. 284 (2003). See <http://www-nrd.nhtsa.dot.gov/pdf/nrd01/esv/esv18/CD/Files/18ESV-000284.pdf>, accessed April 16, 2008.

89 Two-point belts extend across the lap; three-point belts are lap/shoulder combinations.
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Since 1997, EU member states have required two-point lap belts 

and energy-absorbing seats or three-point lap and shoulder belts on all 

M3 motorcoaches.90 Economic Commission for Europe (ECE) Regulation 80 

specifies the strength of seats on large passenger buses (16 or more passengers), 

requiring passengers to remain in the predetermined zone in cases of a 

30-kilometer-per-hour impact. ECE Regulation 14 addresses seat anchorages, and 

ECE Regulation 16 mandates safety belts for occupants of power-driven vehicles. 

The EU has tested a universal motorcoach safety seat that employs a lap/shoulder 

belt to restrain a 50th percentile dummy under the most extreme conditions (as 

defined by ECE Regulation 80) and simultaneously restrains unbelted or lap‐belted 

50th percentile dummies seated behind the test seat. The specified injury criteria 

for lap-belted or unbelted dummies seated behind the test seat are also met 

when the test seat is empty. Recent research considering occupant safety issues 

in EU countries finds that the use of seat belts is strongly recommended during 

vehicle rollover and that the use of lap/shoulder belt systems is recommended for 

front- and rear-impact events.91

Australia applies a set of design rules in addition to ECE requirements.92

The Federal Office of Road Safety in Canberra conducted a 5-year study (1988 to 

1993) of 23 motorcoach accidents to identify occupant protection issues involving 

long distance coaches.93 Since 1994, Australian Design Rule 68/00 has required 

that all newly manufactured motorcoaches have a lap/shoulder belt system.

NHTSA’s 2007 “Approach to Motorcoach Safety” from the Office of 

Crashworthiness Standards states, “Installing seat belts [on motorcoaches] would 

be the most direct method of retaining passengers within a seating compartment.” 

Yet, NHTSA also states that the fundamental information necessary to establish 

adequate performance requirements for seat belts on motorcoaches does not exist. 

Had NHTSA promptly set about defining the FMVSS requirements for motorcoach 

occupant protection following the Safety Board’s 1999 bus crashworthiness special 

investigation, as has been accomplished by the EU and Australia, these standards 

could now be identified for U.S. motorcoaches.94 NHTSA has only recently 

reinstated a program to characterize restraint response in rollovers. Consequently, 

the Safety Board concludes that because of NHTSA’s delay in defining motorcoach 

90 Within the EU, the M-definition of buses provides a common classification of coaches based on weight. 

M3 coaches are defined as weighing more than 5 tons. The M-definitions are further separated into classes I 

through III based on application.

91 E. Mayrhofer, H. Steffan, and, H. Hoschopf, “Enhanced Coach and Bus Occupant Safety,” Proceedings: 

19th International Technical Conference on the Enhanced Safety of Vehicles, Washington, D.C., June 6–9, 

2005, Paper No. 05-0351 (2005). See <http://www-nrd.nhtsa.dot.gov/pdf/nrd-01/esv/esv19/05-0351-O.pdf>, 

accessed April 3, 2008.

92 Australia requires three-point seat belts and 20 g seats.

93 K.B. Smith, “Fatal and Serious Injury Bus Crashes,” Working Document WD117 (Canberra, Australia: 

Federal Office of Road Safety, November 1993).

94 M. Sword and L. Sullivan, “NHTSA Research on Improved Strength in Rollovers,” Proceedings: 20th 

International Technical Conference on the Enhanced Safety of Vehicles, Lyon, France, June 18 through 21, 

2007, Paper No. 07-0297 (2007). See <http://www-nrd.nhtsa.dot.gov/pdf/nrd-01/esv/esv20/07-0279-O.pdf>, 

accessed April 16, 2007.
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occupant protection performance standards, U.S. motorcoaches have not been 

equipped with such systems, leaving the traveling public inadequately protected 

during motorcoach collisions, particularly during rollovers.

Past Investigations and Actions

Between 1968 and 1973, the Safety Board issued a series of recommendations 

to the FHWA and NHTSA concerning occupant protection. Safety 

Recommendation H‐73‐42, calling for bus passenger restraints, was classified 

“Closed—Reconsidered” in June 1988, with the provision that the Safety Board 

would continue to monitor motorcoach accidents to determine whether the 

installation and use of seat belts would mitigate injuries. From 1968 to 1997, the 

Safety Board investigated 36 motorcoach accidents resulting in 168 occupant 

fatalities, 106 (63 percent) of which occurred in accidents involving a rollover.95 Of 

those 106 fatally injured passengers, 64 were ejected.

In 1999, the Safety Board published two special investigation reports96 that 

addressed motorcoach occupant protection; in May 2000, this issue was placed on 

the Safety Board’s Most Wanted List. Two recommendations related to motorcoach 

occupant protection particularly apply to the circumstances of this accident: 

Safety Recommendation H-99-47,97 which calls for the development of standards 

for motorcoach occupant protection systems, and Safety Recommendation H-99-

48, which calls for those systems, once developed, to be required on newly 

manufactured motorcoaches. NHTSA’s initial response indicated that work had 

begun to develop a research plan to accomplish these recommendations. Two 

years later, NHTSA reported forming the Bus Manufacturer’s Council; in 2002, the 

agency held a public forum on motorcoach safety with Transport Canada. During 

meetings with NHTSA in 2004, the Safety Board was informed that the agency was 

focusing on roof crush and window retention technology to keep occupants in the 

vehicle and had initiated a joint study with Transport Canada.

Safety Recommendations H-99-47 and -48, issued as a result of the 

Safety Board’s 1999 bus crashworthiness special investigation, were reiterated in 

2001 following a 1999 motorcoach accident in New Orleans.98 Since 1998, the Safety 

Board has investigated 33 more motorcoach crashes involving 255 ejections and 123 

fatalities (see appendix C). These accidents, the majority of which involve rollover 

crashes, clearly show that passengers who remain in their seating compartments 

sustain fewer injuries and that ejected passengers are the most likely to be killed.

95 See NTSB/SIR-99/04, appendix F, for a list of these accidents.

96 NTSB/SIR-99/04 examined 46 accidents, 36 of which involved motorcoaches; NTSB/SIR-99/01 

examined 2 motorcoach accidents.

97 The Safety Board classified Safety Recommendation H-99-47 “Open—Acceptable Response” at its 

November 8, 2007, progress meeting and update of Most Wanted issues.

98 NTSB/HAR-01/01.
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Today, 9 years after the Safety Board concluded in its bus crashworthiness 

special investigation that one of the primary causes of preventable injury in 

motorcoach accidents involving rollover and/or ejection is occupant motion 

out of the seating compartment, no Federal regulations or standards require 

that motorcoaches operated in the United States be equipped with occupant 

protection systems.99 Consequently, the Safety Board again reiterates the following 

recommendations to NHTSA:

H-99-47

In 2 years, develop performance standards for motorcoach occupant 

protection systems that account for frontal impact collisions, side impact 

collisions, and rollovers.

H-99-48

Once pertinent standards have been developed for motorcoach occupant 

protection systems, require newly manufactured motorcoaches to have 

an occupant crash protection system that meets the newly developed 

performance standards and retains passengers, including those in child 

safety restraint systems, within the seating compartment throughout the 

accident sequence for all accident scenarios.

The Safety Board recognizes that NHTSA has recently conducted crash 

tests and, in fact, Safety Board investigators observed a frontal motorcoach crash 

test performed in December 2007 at the Vehicle Research and Test Center and two 

tests of motorcoach roof strength and occupant survivable space performed in 

February 2008 by the MGA Research Corporation, under contract to NHTSA.100

The Safety Board will carefully follow the analysis of those test results.

The Safety Board notes that, based on accident statistics, motorcoaches 

are among the safest vehicles on the road. However, motorcoaches transport a 

substantial number of people traveling in a single vehicle with a high exposure 

to crash risk;101 typically involve commercial fees for travel; and operate with 

established systems for inspections, specialized training, and driver medical 

requirements. Moreover, special populations, such as students and older adults, 

rely on motorcoach travel. These factors demand that motorcoaches meet the 

highest level of safety.

99 Except for restraints at the driver’s position.

100 These tests used the following protocols: FMVSS 220, School Bus Rollover Protection, which 

involves loading the vehicle roof using a force 1.5 times its unloaded weight, and international standard 

ECE Regulation 66, Uniform Provisions Concerning the Approval of Large Passenger Vehicles With Regard 

to the Strength of Their Superstructure, which involves a rollover test from a tilt platform.

101 Motorcoaches transport 631 million passengers annually. VanHool recently introduced an 

80-passenger, double-decked motorcoach, model TD925, into the U.S. market. Such large-capacity vehicles 

have the potential to further increase the number of passengers involved per accident.
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Conclusions

Findings

1. The following factors neither caused nor contributed to the accident: the 

weather; the mechanical condition of the vehicle; the driver’s qualifications and 

driving record; or driver impairment due to alcohol, illicit drugs, or narcotic 

pain medication.

2. The emergency response was timely and effective.

3. The Georgia Department of Transportation failed to identify the Northside 

Drive HOV-only left exit, which was in a left curve preceding a high-speed left 

interstate merge, as an unexpected arrangement that required additional traffic 

control devices to guide road users.

4. The Georgia Department of Transportation, in changing the original design 

plan by separating the Northside Drive HOV exit sign from the Interstate 75 

South pull-through sign, caused the effective meaning of the paired signs to be 

lost at a critical decision point on the highway.

5. Positioning the Northside Drive HOV-only left exit direction sign next to 

the Interstate 75 South pull-through sign will promote positive guidance to 

motorists on the appropriate travel lanes at a critical decision point on the 

highway.

6. Because of the unique combination of geometric features and lane restrictions 

of an HOV-only left exit, redesigning the Northside Drive exit signs to include a 

message plaque with the legend LEFT in black on a yellow background placed 

at the top left edge of the 1 MILE and 1/2 MILE guide signs will better alert 

drivers to the unconventional exit design.

7. Because the Northside Drive exit ramp is short and terminates at a nonsignalized 

intersection, an advisory ramp speed sign is needed for motorist safety.

8. The use of yellow dashed lines for left exit pavement markings and white dashed 

lines for right exit pavement markings should be considered to emphasize and 

distinguish left exits.

9. Pairing an EXIT pavement marking with the HOV diamond pavement marking 

is a useful traffic control enhancement for all left HOV exits.
Conclusions

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10. This accident illustrates the importance of HOV traffic control devices 

being sufficiently similar, regardless of their geographic location, to create 

consistent expectations related to common geometric, operational, and route 

characteristics.

11. The supplemental LEFT message plaques required by the Manual on Uniform 

Traffic Control Devices’ proposed standard should be phased in sooner than the 

typical 10-year compliance timeframe.

12. The investigation found no evidence of the driver being asleep or otherwise 

incapacitated prior to the accident.

13. Executive Coach Luxury Travel, Inc., inadequately monitored its drivers to 

determine their compliance with the Federal Motor Carrier Safety Regulations

related to motorcoach operation.

14. Information on the acceleration time history (or crash pulses) critical to 

the evaluation of vehicle performance and occupant protection systems 

was unavailable to accident investigators and researchers because of the 

motorcoach’s lack of an event data recorder.

15. Event data recorders would provide the accurate and detailed event data 

necessary to better understand crash causation and to establish design 

requirements for motorcoach crashworthiness and occupant protection 

systems.

16. Establishing event data recorder performance standards for motorcoaches and 

buses is necessary for the timely and efficient implementation of event data 

recorders, which will, in turn, provide the data needed to develop effective 

occupant protection systems.

17. Because of the National Highway Traffic Safety Administration’s delay 

in defining motorcoach occupant protection performance standards, 

U.S. motorcoaches have not been equipped with such systems, leaving 

the traveling public inadequately protected during motorcoach collisions, 

particularly during rollovers.
Conclusions

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Probable Cause

The National Transportation Safety Board determines that the probable 

cause of this accident was the motorcoach driver’s mistaking the HOV-only left 

exit ramp to Northside Drive for the southbound Interstate 75 HOV through lane. 

Contributing to the accident driver’s route mistake was the failure of the Georgia 

Department of Transportation to install adequate traffic control devices to identify 

the separation and divergence of the Northside Drive HOV-only left exit ramp 

from the southbound Interstate 75 HOV through lane. Contributing to the severity 

of the accident was the motorcoach’s lack of an adequate occupant protection 

system.
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Recommendations

New Recommendations

As a result of its investigation of this accident, the National Transportation 

Safety Board makes the following safety recommendations:

To the Federal Highway Administration:

Include in a Manual on Uniform Traffic Control Devices standard the 

requirements for HOV-only left exits to have LEFT message plaques 

on all exit guide signs and for exit direction (arrow) signs to be 

positioned next to pull-through signs at exits with limited sight 

distance, short ramps, or multiple route choices. (H-08-3)

Include in a Manual on Uniform Traffic Control Devices standard 

criteria for the use of advisory speed limit signs for all interstate exit 

ramps. (H-08-4)

Evaluate the Manual on Uniform Traffic Control Devices standard for 

guide line marking requirements for interstate left exits. (H-08-5)

Work with the National Committee on Uniform Traffic Control 

Devices to ensure that the next edition of the Manual on Uniform 

Traffic Control Devices is issued as scheduled in 2008 and that the 

revision comprehensively addresses the uniformity of HOV traffic 

control devices, including left exits. (H-08-6)

Require a phase-in period of 5 years for supplemental LEFT message 

plaques in the standard proposed for the next edition of the Manual 

on Uniform Traffic Control Devices. (H-08-7)

To the Georgia Department of Transportation:

Install a LEFT message plaque on the 1 MILE and the 1/2 MILE

advance exit guide signs and on the directional arrow exit sign 

for Northside Drive and position the pull-through sign for the 

southbound Interstate 75 HOV through lane so that it is next to the 

Northside Drive left-exit direction sign. (H-08-8)

Install exit signs with LEFT message plaques for left interstate exits. 

(H-08-9)
Recommendations

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Install pull-through signs next to the exit direction (arrow) signs to 

ensure positive route guidance at exits with limited sight distance, 

short ramps, or multiple route choices (H-08-10).

Install an advisory speed limit sign (Manual on Uniform Traffic 

Control Devices W13-2) on the Northside Drive HOV exit ramp and 

on interstate left exit ramps throughout the State. (H-08-11)

Add an EXIT pavement marking paired with the HOV diamond 

pavement marking at all left HOV interstate exits. (H-08-12)

Reiterated Recommendations

The National Transportation Safety Board reiterates the following 

recommendations:

To the National Highway Traffic Safety Administration:

In 2 years, develop performance standards for motorcoach occupant 

protection systems that account for frontal impact collisions, side 

impact collisions, rear impact collisions, and rollovers. (H-99-47)

Once pertinent standards have been developed for motorcoach 

occupant protection systems, require newly manufactured 

motorcoaches to have an occupant crash protection system that 

meets the newly developed performance standards and retains 

passengers, including those in child safety restraint systems, within 

the seating compartment throughout the accident sequence for all 

accident scenarios. (H-99-48)

Require that all school buses and motorcoaches manufactured after 

January 1, 2003, be equipped with on-board recording systems 

that record vehicle parameters, including, at a minimum, lateral 

acceleration, longitudinal acceleration, vertical acceleration, heading, 

vehicle speed, engine speed, driver’s seat belt status, braking input, 

steering input, gear selection, turn signal status (left/right), brake 

light status (on/off), head/tail light status (on/off), passenger door 

status (open/closed), emergency door status (open/closed), hazard 

light status (on/off), brake system status (normal/warning), and 

flashing red light status (on/off) (school buses only). For those 

buses so equipped, the following should also be recorded: status of 

additional seat belts, airbag deployment criteria, airbag deployment 

time, and airbag deployment energy. The on-board recording system 

should record data at a sampling rate that is sufficient to define 

vehicle dynamics and should be capable of preserving data in the 
Recommendations

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event of a vehicle crash or an electrical power loss. In addition, the 

on-board recording system should be mounted to the bus body, not 

the chassis, to ensure that the data necessary for defining bus body 

motion are recorded. (H-99-53)

Develop and implement, in cooperation with other Government 

agencies and industry, standards for on-board recording of bus 

crash data that address, at a minimum, parameters to be recorded, 

data sampling rates, duration of recording, interface configurations, 

data storage format, incorporation of fleet management tools, fluid 

immersion survivability, impact shock survivability, crush and 

penetration survivability, fire survivability, independent power 

supply, and ability to accommodate future requirements and 

technological advances. (H-99-54)

BY THE NATIONAL TRANSPORTATION SAFETY BOARD

MARK V. ROSENKER DEBORAH A. P. HERSMAN

Chairman Member

ROBERT L. SUMWALT KATHRYN O’LEARY HIGGINS

Vice Chairman Member

STEVEN R. CHEALANDER

Member

Adopted: July 8, 2008

Member Hersman filed the following concurring statement on July 16, 2008, 

and was joined by Vice Chairman Sumwalt.
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Board Member Statement

Member Hersman, concurring

The focus of this accident report is a tricky highway configuration and 

the placement of signage that was not adequate to safely guide drivers through 

a difficult interchange. The findings, probable cause, and recommendations 

concentrate on those two issues, as they should. However, a couple of facts that 

came out of this accident provide the perfect illustration of a safety issue that, 

while not the spotlight of this accident cause, will increasingly become a focal 

point of highway accidents in the years ahead.

The 65-year-old driver mistakenly drove his motorcoach at highway speed 

up an exit ramp, perhaps thinking that he was following the HOV lane to merge 

with another interstate highway. His actions in this crash repeated eight other 

similar crashes at this same interchange during the past ten years. All nine crashes 

involved drivers who apparently mistook the exit ramp for the HOV lane, and all 

nine crashes involved drivers who were over the age of 50. I don’t believe this was 

a coincidence.

According to the Federal Highway Administration (FHWA), an exit gore 

on a highway presents a particular challenge to the older driver. The driver has to 

process a lot of directional information in a short time at a high rate of speed while 

moving with the traffic stream. In this type of situation, the chances are greater 

that the driver will become overloaded and make mistakes if the driver is older, 

according to the FHWA.

Safety Board investigators found that there have been other incidences of 

drivers mistaking this exit ramp for a continuation of the HOV lane when several 

people volunteered information about how they nearly crashed at this interchange. 

We will never know how many drivers have almost had a crash at this interchange 

because these near-accidents are not reported unless someone volunteers the 

information. Not all of the people who reported their near-accidents were older 

drivers, so we can assume with some certainty that not all of the people who 

experienced near-accidents at this interchange were older. However, all of the nine 

drivers who did crash at this interchange were older. They thus illustrate the point 

I attempted to make at the Board meeting and will attempt to make again here: 

older drivers, because of their age-related characteristics, are the drivers who point 

out for all of us the interchanges, intersections, highway designs, and signs that 

are most in need of attention to improve safety. Older drivers are like the canaries 

in the coal mine—they show us where there is danger because in comparison 

to most other drivers, they are less likely to be able to quickly compensate for 

confusing highway and traffic configurations and misleading or ill-placed signs. 

At this interchange on I-75 in Atlanta, those uncounted drivers who mistook the 
Board Member Statement

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exit ramp for the HOV lane but managed to avoid a crash did not point out its 

dangers; the nine older drivers who crashed did.

Older drivers may experience difficulty at highway interchanges and other 

complex driving situations because of diminished capabilities typically related 

to age. For example, they have reduced night vision and contrast sensitivity. For 

every decade after age 25, drivers need twice the brightness at night to receive 

visual information. Hence, by the time some drivers reach the age of 75, they need 

32 times the brightness they required at age 25. Older drivers also experience 

slowed response time and information-processing ability. The have a reduced 

ability to quickly localize the most relevant stimuli in a driving situation, and they 

are not as efficient in switching attention between multiple targets (e.g., noting 

road signs while attempting to change lanes). They typically have some loss of 

vision, and they frequently experience increased sensitivity to glare.

These factors do not make older drivers inherently poor drivers, but they are 

more challenging for older drivers than for their younger counterparts. However, 

these very same factors also make it more obvious to the highway designers and 

engineers, who may not share these characteristics yet, where improvements should 

be made. Design improvements for older drivers are already outlined in FHWA 

and AASHTO guidance. These improvements include, among other things, better 

signage with larger type and placement for longer reaction time, advance warning 

signs indicating hazardous conditions on or near the road, improved lighting at 

intersections, horizontal curves and railroad grade crossings, improved pavement 

markings and raised lane channelization. Unfortunately, these guidelines are not 

universally followed.

If we think about the experiences of older drivers as beacons pointing 

us to the most needed safety improvements, the beacons will be shining a lot 

more brightly in the coming years. According to the National Highway Traffic 

Safety Administration, the number of licensed drivers aged 65 and older rose by 

18% between 1996 and 2006. During that same time period, the total number of 

licensed drivers increased by only 13%. This means that our driving population 

is becoming proportionately older by a significant margin. In fact, the number 

of older drivers on the road is expected to double in the next 20 years. By the 

year 2030, just 22 years away, every fifth person on the road will be elderly. Right 

now, older drivers account for 16% of all traffic crashes. That rate will surely rise as 

our driving population gets older. The time is now to start making design changes 

in our highways that will accommodate our aging driving population so that when 

we get to 2030, our crash rate does not rise to unprecedented levels.

The Safety Board has consistently approached highway safety by 

addressing recommended improvements for discrete segments of the driving 

community: novice drivers, drinking drivers, motorcyclists, and commercial 

drivers. I recognize that any category of drivers is not monolithic, and that fact 

is true of older drivers. There are, however, characteristics common to many 

drivers in this segment of the driving community, and we should be mindful 
Board Member Statement

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of those characteristics as our population ages. It is appropriate and timely for 

us to begin exploring improvements to safeguard the older driver segment, a 

group that is going to increase in size dramatically in the next two decades. We 

should use our older drivers as guides to point out the areas most in need of 

safety improvement and we should make design changes for them. If our streets, 

highways, intersections, signs, and signals are designed with the older driver 

in mind, they will be safer, not just for the older drivers among us, but for all

drivers.

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Appendix A

Investigation

The National Transportation Safety Board was notified of the Atlanta 

accident on March 2, 2007. An investigative team was dispatched with members 

from the Washington, D.C., and Arlington, Texas, offices. Member Higgins was 

the member on scene. Groups were established to investigate human performance, 

motor carrier operations, event data, highway, vehicle, and survival factors.

Participating in the investigation were representatives of the Federal 

Highway Administration (FHWA), the Georgia Department of Transportation 

(GDOT), the Atlanta Police Department, and the Fulton County Police Department. 

Technical review of the Safety Board’s factual material was completed on 

April 29, 2008. Participating parties included the Federal Motor Carrier Safety 

Administration, FHWA, and GDOT.

No public hearing was held and no depositions were taken.

In January 2008, Executive Coach Luxury Travel, Inc., was sold and is no 

longer operating.
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Appendix B

Accident History for the Northside Drive Exit, 1997–2007

Date and 

time Injuries Fatalities Collision type

Object 

struck Light Surface Vehicle 1 Vehicle 2

12/1/97

12:50 a.m. 2 0 Single vehicle Bridge rail Dark(lighted) Dry Straight n/a

12/24/98

3:50 p.m. 0 0 Angle Vehicle in motion Daylight Wet Changing lanes Straight

10/17/99

9:10 p.m. 0 0 Single vehicle Curb Dark(lighted) Dry Straight n/a

12/27/00

10:55 a.m. 4 0 Angle Vehicle in motion Daylight Dry Changing lanes Straight

2/24/01

9:52 p.m. 1 1 Single vehicle Bridge rail Dark(lighted) Dry Straight n/a

1/20/02

4:00 a.m. 2 0 Single vehicle

Fixed 

object

Dark

(lighted) Wet Straight n/a

8/11/02

9:41 a.m. 2 1 Single vehicle

Fixed 

object Daylight Dry Straight n/a

1/15/03

10:35 a.m. 3 0 Head on Vehicle in motion Daylight Dry Straight Straight

3/2/07

5:38 a.m. 28 7 Single vehicle Bridge rail Dark(lighted) Dry Straight n/a
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Appendix C

Safety Board Motorcoach Accident Investigations

The National Transportation Safety Board’s 1999 special investigation 

on bus crashworthiness issues1 included statistics on 36 motorcoach accidents 

investigated by the Safety Board from 1968 through 1997. This appendix 

summarizes 33 frontal crash and rollover accidents investigated by the 

Safety Board (major accidents, field investigations, and incidents) since 1998. The 

table accounts for motorcoach passengers, not drivers, because drivers’ use of seat 

belts decreases the likelihood of ejection.

Table 1. Motorcoach Accidents Investigated by the Safety Board Since 1998

Year Accident Fatalities Injuries Ejections Crash type

1 1998 Burnt Cabins, PA

(HWY-98-MH-033) 6 16 0 Frontal impact

2 1998 Old Bridge, NJ

(HWY-98-MH-033) 8 14 7 Rollover

3 1999 Santa Fe, NM

(HWY-99-FH-012) 2 35A 1 Rollover

4 1999 New Orleans, LA

(HWY-99-MH-017) 22 21 10 Frontal impactB

5 1999 Braidwood, IL

(HWY-99-FH-017) 1 23 2 Rollover

6 1999 Canon City, CO

(HWY-00-FH-011) 2 57 53 Rollover

7 2000 Eureka, MO

(HWY-00-IH-051) 0 25 0 Frontal impact

8 2001 Allamuchy, NJ

(HWY-01-FH-011) 0 39 0 Rollover

9 2001 Bay St. Louis, MO

(HWY-01-IH-024) 0 16 0 Frontal impactB

10 2001 Fairplay, CO

(HWY-01-IH-028) 0 45 12 Rollover

11 2001 Pleasant View, TN

(HWY-01-FH-03) 1 43 1 Rollover

12 2002 Manchester, TN

(HWY-02-IH-002) 6 UnknownC 6 Rollover

13 2002 Loraine, TX

(HWY-02-MH-021) 3 29 0 Frontal Impact

1 National Transportation Safety Board, Bus Crashworthiness Issues, Highway Special Investigation 

Report NTSB/SIR-99/04 (Washington, DC: NTSB, 1999).
Appendix C

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Year Accident Fatalities Injuries Ejections Crash type

14 2002 Victor, NY

(HWY-02-MH-025) 5 41 6 Rollover

15 2002 Nephi, UT

(HWY-03-IH-001) 6 20 13 Rollover

16 2003 Hewitt, TX

(HWY-03-MH-022) 5 29 15 Rollover

17 2003 Tallulah, LA

(HWY-04-MH-002) 8 6 1 Frontal impact

18 2003 Apache Co., AZ

(HWY-04-IH-007) 0 44 0 Rollover

19 2004 North Hudson, NY

(HWY-04-FH-015) 0 47 0 Frontal impact

20 2003 Anahuac, TX

(HWY-04-FH-026) 1 35 0 Frontal impact

21 2004 Phoenix, AZ

(HWY-04-IH-029) 1 38 0 Frontal impact

22 2004 Jackson, TN

(HWY-04-IH-035) 2 18 0 Frontal impact

23 2004 Turrell, AR

(HWY-05-MH-006) 14 15 30 Rollover

24 2005 Geneseo, NY

(HWY-05-FH-017) 3 20 0 Frontal impact

25 2005 Baltimore, MD

(HWY-05-FH-031) 0 33 0 Rollover

26 2005 Osseo, WI

(HWY-06-MH-003) 4 35 1 Frontal impact

27 2006 Westport, NY

(HWY-06-MH-026) 4 48 22 Rollover

28 2006 Auburn, MA

(HWY-06-IH-028) 0 34 0 Rollover

29 2007 Atlanta, GA

(HWY-07-MH-015) 6 28 12 Frontal/rollover

30 2007 Clearfield, PA

(HWY-07-IH-020) 2 25 2 Rollover

31 2007 Bowling Green, KY

(HWY-07-IH-022) 1 64 10 Rollover

32 2008 Victoria, TX D

(HWY-08-MH-001) 1 46 1 Rollover

33 2008 Mexican Hat, UT

(HWY-08-MH-012) 9 42 50 Rollover

Total 123 1,031 255

ADriver injuries unknown.

BRun-off-road, then frontal impact into terrain.

CDriver attacked by passenger; subsequent injuries unknown.

DLap belts availlable; none reportedly were used.