National 

Transportation

Safety Board

Washington, D.C.

National Transportation

Safety Board

Washington, D.C. 20594

OFFICIAL BUSINESS

Penalty for Private Use, $300

PRSRT STD

Postage & Fees Paid

NTSB

Permit No. G-200

Highway Accident Report

Motorcoach Run-off-the-Road

and Rollover off Interstate 90

Victor, New York

June 23, 2002

NTSB/HAR-04/03

PB2004-916203 National Transportation Safety Board

Notation 7643 490 L’Enfant Plaza, S.W.

Adopted June 22, 2004 Washington, D.C. 20594
National Transportation Safety Board. 2004. Motorcoach Run-off-the-Road and Rollover off

Interstate 90, Victor, New York, on June 23, 2002. Highway Accident Report NTSB/HAR-04/03.

Washington, DC.

Abstract: On June 23, 2002, a 55-passenger Motor Coach Industries, Inc., motorcoach was traveling

eastbound on Interstate 90 near Victor, New York. As it approached the Victor Exit 45 ramp, the bus

departed the road; struck a W-beam guardrail, dragging about 700 feet of it across the eastbound entrance

ramp; vaulted over the entrance ramp, landing on the ramp’s south side shoulder; and rolled 90 degrees

onto its right side, sliding to rest. The guardrail dragged by the bus during the accident sequence struck

three eastbound vehicles on the entrance ramp. Three occupants of these vehicles were uninjured, and six

received minor injuries. Of the 48 people on the motorcoach, 5 passengers were killed; the driver and 41

passengers sustained injuries; and 1 passenger was uninjured.

The safety issues discussed in this report are operator fatigue, motorcoach crashworthiness, and the

adequacy of the Federal Motor Carrier Safety Administration’s oversight of and rating system for

motorcoach operations.

As a result its investigation, the Safety Board makes new recommendations to the Federal Motor Carrier

Safety Administration, the U.S. Department of Defense Surface Deployment and Distribution Command,

and Coach USA. Also, the Board reiterates Safety Recommendations H-99-47 and -48 to the National

Highway Traffic Safety Administration.

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

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

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

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

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

statistical reviews.

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

may be obtained from the Web site or by contacting:

National Transportation Safety Board

Public Inquiries Section, RE-51

490 L’Enfant Plaza, S.W.

Washington, D.C. 20594

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

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

purchase this publication, order report number PB2004-916203 from:

National Technical Information Service

5285 Port Royal Road

Springfield, Virginia 22161

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

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

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

Contents

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

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

Factual . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1

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

Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1

Events Preceding the Accident . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6

Injuries . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7

Emergency Response . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7

Meteorological Information . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8

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

Motorcoach Information . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11

Wreckage Information . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11

Highway Information . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12

Highway Design . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12

Victor Exit 45 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13

Traffic Information . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13

Operations Information . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13

Arrow Line, Inc. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13

Coach USA . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15

Peter Pan Bus Lines, Inc. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 16

FMCSA Compliance Review Program . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17

SafeStat . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 20

DOT Office of the Inspector General Audit Findings . . . . . . . . . . . . . . . . . . . . . . . . . . 22

ISS-2 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 24

U.S. Department of Defense . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 25

Tests and Research . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 26

Accident Reconstruction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 26

Accident Simulation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 26

Motorcoach Crashworthiness in Other Countries . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 27

Analysis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 29

Exclusions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 29

Accident Discussion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 30

Bus Driver Performance . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 31

Off-Duty Hours . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 31

Operator Fatigue . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 33

Driver’s Alert Program . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 35

Motor Carrier and Federal Regulations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 40

U.S. Department of Defense . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 40

SafeStat . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 41

Compliance Reviews and Safety Rating Effectiveness . . . . . . . . . . . . . . . . . . . . . . . . . 42

Survival Aspects and Motorcoach Crashworthiness . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 45
Contents iv Highway Accident Report

Conclusions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 49

Findings . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 49

Probable Cause . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 50

Recommendations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 51

New Recommendations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 51

Reiterated Recommendations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 51

Appendixes

A: Investigation and Public Hearing . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 53

B: Arrow Compliance Review and Safety Rating History . . . . . . . . . . . . . . . . . . . . . . . . . . 54

C: Safety Evaluation Area Criteria. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 55

D: ISS-2 Recommendation and Inspection Values. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 56

E: FMCSA Compliance Reviews and Roadside Inspections . . . . . . . . . . . . . . . . . . . . . . . . 57

F: October 2002 FMCSA Compliance Review of Arrow Line, Inc.. . . . . . . . . . . . . . . . . . 58

G: DOT Office of Inspector General Report. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 60
v Highway Accident Report

Acronyms and Abbreviations

Arrow Arrow Line, Inc.

CDL commercial driver’s license

CFR Code of Federal Regulations

DoD U.S. Department of Defense

DOT U.S. Department of Transportation

ECM electronic control module

FHWA Federal Highway Administration

FMCSA Federal Motor Carrier Safety Administration

FMCSRs Federal Motor Carrier Safety Regulations

Greyhound Greyhound Lines, Inc.

IG Office of the Inspector General

ISS-2 Inspection Selection System

I-90 Interstate 90

MCMIS Motor Carrier Management Information System

MCSIA Motor Carrier Safety Improvement Act

motorcoach 2 second chartered bus

MTMC Military Traffic Management Command

NHTSA National Highway Traffic Safety Administration

NYSP New York State Police

Peter Pan Peter Pan Bus Lines, Inc.

SafeStat Safety Status Measurement System

SDDC Surface Deployment and Distribution Command

SEA Safety Evaluation Area
vi Highway Accident Report

Executive Summary

At 2:56 p.m. on June 23, 2002, a 1998 Motor Coach Industries, 55-passenger

motorcoach, operated by Arrow Line, Inc., a Coach USA subsidiary, was traveling

eastbound between 60 and 63 mph on Interstate 90 near Victor, New York. The

motorcoach, carrying 47 passengers, was en route from Niagara Falls, Ontario, Canada, to

Waterbury, Connecticut. As the bus approached the Victor Exit 45 ramp, the vehicle

departed the roadway and proceeded into the depressed grassy area between the eastbound

exit and entrance ramps. The motorcoach then struck a W-beam guardrail, dragged

approximately 700 feet of the guardrail across the eastbound entrance ramp, vaulted over

the entrance ramp roadway, landed on the south side shoulder of the entrance ramp, rolled

90 degrees onto its right side, and slid to rest. The guardrail dragged by the motorcoach

then struck three eastbound vehicles on the entrance ramp. Three occupants of these

vehicles were uninjured, and six received minor injuries. Of the 48 people on the

motorcoach, 5 passengers were killed; the driver and 41 passengers sustained injuries; and

1 passenger was uninjured.

The National Transportation Safety Board determines that the probable cause of

the accident was that the bus driver fell asleep while operating the motorcoach due to his

deliberate failure to obtain adequate rest during his off-duty hours. Contributing to the

cause of the accident was the second Arrow Line, Inc., motorcoach driver, who did

nothing to prevent the severely fatigued driver from operating the accident motorcoach,

and the failure of Arrow Line, Inc., and its holding company, Coach USA, to provide

adequate oversight of their drivers. Contributing to the severity of the accident was the

lack of occupant restraints for the motorcoach passengers.

The safety issues identified in this accident are operator fatigue, motorcoach

crashworthiness, and the adequacy of the Federal Motor Carrier Safety Administration’s

oversight of and rating system for motorcoach operations.

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

recommendations to the Federal Motor Carrier Safety Administration, the U.S.

Department of Defense Surface Deployment and Distribution Command, and Coach USA

and its subsidiaries. Also, the Safety Board reiterates Safety Recommendations H-99-47

and -48 to the National Highway Traffic Safety Administration.
1 Highway Accident Report

Factual

Accident Narrative

Introduction

At 2:56 p.m. on June 23, 2002, a 1998 Motor Coach Industries, 55-passenger

motorcoach, operated by Arrow Line, Inc. (Arrow), a Coach USA subsidiary, was

traveling eastbound on Interstate 90 (I-90) near Victor, New York. (See figures 1 and 2.)

The motorcoach, carrying 47 passengers, was en route from Niagara Falls, Ontario,

Canada, to Waterbury, Connecticut.

Figure 1. Regional view of accident site. 

Lake Ontario

Lake E rie 

Niagara 

Falls 

CANADA 

PE NNS YLVANIA

ONTAR IO

90 

N E W Y O R K

Atlantic Ocean 

VE R MONT

NE W HAMP S HIR E

NE W JE R S E Y

MAS S AC HUS E TTS

Waterbury

V ic tor

A c c ident S ite

490 

H udson R vi er

90 

UNITE D S TATES

90 

CONNE CTICUT

91 

N

MP 350.9
Factual 2 Highway Accident Report

As the motorcoach approached the Victor Exit 45 ramp (milepost 350.9), the

vehicle left the roadway and drove across the paved gore1

 area into the depressed grassy

gore area between the eastbound exit and entrance ramps. The motorcoach proceeded

across the grassy gore area, struck a W-beam guardrail, and dragged about 700 feet of the

guardrail across the entrance ramp. The motorcoach then vaulted over the ramp. The

guardrail struck a 2003 Pontiac Vibe, a 1997 Ford Expedition, and a 1998 Buick LeSabre.

After the motorcoach landed on the descending shoulder of the south side of the entrance

ramp, it rolled 90 degrees onto its right side and came to rest at the bottom of the

embankment near the guardrail for Willowbrook Road. (See figures 3 and 4.) Five bus

passengers were killed, 7 passengers sustained serious injuries, the bus driver and 34

passengers had minor injuries, and 1 passenger was not injured. In the three passenger

vehicles, six occupants sustained minor injuries, and three occupants were uninjured.

Figure 2. Local view of accident site.

1 The term “gore” refers to the area between a through roadway and an exit ramp or the area between a

through roadway and a converging entrance ramp.

Victor Road

Accident Site

Exit 45

9 50

96

90

42

490

East Victor

Doughton Hill Hathaway Corners

Motts Corner

251

332

444

41

N
Factual 3 Highway Accident Report

Figure 3. Schematic of accident site. (Source: New York State Police)
Factual 4 Highway Accident Report

Witness Information. The driver of a vehicle that had passed the motorcoach

moments before the accident told the New York State Police (NYSP) that when she was

traveling behind the motorcoach, she observed the bus being driven erratically. She said

that the motorcoach generally stayed within its lane, but alternately went slow and fast and

at times swerved and drifted. She attempted twice to pass the motorcoach on its left. In

both instances, the motorcoach swerved to the left in its lane, nearly striking her vehicle.

She sounded her horn and dropped back behind the motorcoach. As both vehicles

Figure 4. View of accident motorcoach at rest. (Source: New York State Police)
Factual 5 Highway Accident Report

approached Victor Exit 45, she again tried to pass the motorcoach and stated that when she

did so, the motorcoach drove into the middle lane, forcing her into the far left lane to avoid

a collision. After passing the motorcoach, she did not see it again.

Passenger Statements. Passengers reported to Safety Board investigators2 that

throughout the trip preceding the accident, the bus driver appeared sleepy and was seen

rubbing his eyes, wiping his face, and resting his chin in his hands as he held the steering

wheel with his elbows. In his statements to the NYSP, the accident driver denied falling

asleep at the wheel and reported having a habit of stretching, rubbing his face and neck,

and squirming in his seat while driving. 

One passenger said that he used the intercom speaker to tell the other passengers in

Spanish that the bus driver was sleepy and explained that they needed to help keep the

driver awake. This passenger reported that the bus driver had driven over the right

shoulder rumble strips3

 and back into the lane about six times. Another passenger and his

wife reported they noticed the driver repeatedly touching his arms and face while driving.

A passenger seated in the right-side first row aisle position stated that she observed the bus

driver driving down the middle of the interstate between the two lanes and that another

time the motorcoach almost sideswiped a parked truck on the roadside. Another passenger

stated that just before the accident, the speedometer read between 75 and 80 mph,4 and the

driver was steering with his elbow while smoking a cigarette.

Passengers reported that one passenger, who was seated in the rear of the

motorcoach, was concerned about the driver’s aggressive lane changes and drifting within

the lane. She went to the front of the bus and asked the driver to pull over but the driver

rebuffed her request. (Passengers described the driver’s manner as impatient and irritable.)

Moments later, as the passenger returned to her seat, the motorcoach began to drift onto

the right shoulder as it approached Victor Exit 45 and proceeded over the gore strip’s

raised thermoplastic lines, which resulted in an auditory and vibratory warning. According

to passenger statements, a frightened passenger cried out, possibly startling the driver; one

passenger thought that the driver might have interpreted the cry as a signal to take the exit

that they were about to pass. A passenger seated in the right front seat said that as the

motorcoach passed the exit ramp, the driver, who was driving with his elbows on the

steering wheel, “shook his head and grabbed the steering wheel with both hands.” Many

passengers stated that just before the accident, they felt the motorcoach swerve to the right

and attempted to grab onto the seat in front of them to keep from sliding out of their seats.

Some passengers carried cellular telephones but did not use the telephones before the

accident to report the driver’s behavior. When asked what they believed would have

helped to prevent the accident, several passengers answered that having a telephone on

board the motorcoach with a direct line to call either 9-1-1 or an 800 number to the bus

driver’s employer may have helped.

2 The Safety Board interviewed 15 of the accident bus passengers; this section summarizes their

statements.

3 Rumble strips or “audible roadway delineators” are raised or grooved patterns on roadway shoulders

that provide both an audible warning and physical vibration that alerts drivers when they leave the roadway.

4 The motorcoach had an engine governor, limiting the maximum engine speed to 70 mph.
Factual 6 Highway Accident Report

Events Preceding the Accident

About 11:00 p.m. on Thursday, June 20, 2002, the accident bus departed

Waterbury and a second chartered bus (motorcoach 2) departed Manhattan for a trip to

Niagara Falls sponsored by a Waterbury church. The accident motorcoach met

motorcoach 2 at the Canadian border, and both proceeded to a Niagara Falls hotel. The

accident bus driver told the NYSP that he arrived at the hotel about 7:30 a.m. on Friday,

June 21, 2002. The group organizers scheduled both motorcoaches to visit Marineland on

Saturday, June 22, 2002. The motorcoach operators had no other scheduled driving duties

until the return trip on Sunday, June 23, 2002.

The motorcoach 2 driver told the NYSP that he spoke with the accident bus driver

on Saturday morning, when the accident driver stopped by his hotel room and said that he

had won $4,000 at the casinos. According to the motorcoach 2 driver’s statements, he

knew that the accident driver slept for about 3 hours in the bus while the tour group was at

Marineland, and he observed the accident driver getting into a cab to go to the casino

around 5:00 p.m. on Saturday. 

The accident driver informed the NYSP that he had been at the casino from noon

on Friday until about 10:00 a.m. on Saturday, when he went back to his hotel room but did

not sleep. Both motorcoaches departed the hotel around noon on Saturday and transported

passengers to Marineland. The accident bus driver said that he remained with his

motorcoach, napped about 3 hours, and left for the hotel with his passengers about 4:00

p.m. According to the accident bus driver, he showered at the hotel and then left for the

casinos, where he remained until approximately 9:00 a.m. on Sunday morning.

About 8:30 a.m. on Sunday, June 23, the motorcoach 2 driver prepared his vehicle

for the return trip boarding. According to the group organizers, when, at their request,

hotel staff attempted to summon the accident bus driver from his room around 9:30 a.m.,

the accident bus driver did not answer. The motorcoach 2 driver told the NYSP that he saw

the accident bus driver arrive at the hotel about 9:30 a.m., and the accident bus driver said

that he had lost the money overnight that he had won the previous evening. The accident

bus driver showed up at his motorcoach shortly before 11:00 a.m. (the scheduled departure

time), opened the luggage compartment, took his seat behind the wheel, and slept while

passengers loaded their luggage onto the motorcoach. Because one group organizer

expressed her concern to the motorcoach 2 driver that the accident bus driver did not

appear fit to drive, he roused the accident bus driver and asked whether he was all right to

drive. The accident bus driver replied, “Yes, I’m fine.” The motorcoach 2 driver planned

to return directly to Manhattan; the accident bus driver planned to stop at two or three

attractions before returning to Waterbury. The two motorcoaches departed about 12:30 p.m.
Factual 7 Highway Accident Report

Injuries

Table 1. Injuries.

The five passengers who sustained fatal injuries were ejected and received severe

injuries to the head, upper torso, internal organs, and extremities. These passengers were

seated in rows 9, 10, 12, 13, and 14. Figure 5 shows the passengers’ seating positions on the

accident bus. The seven seriously injured passengers sustained blunt trauma to the head,

upper torso, and extremities; one was reportedly ejected through the front windshield. The

minor injuries consisted of abrasions, contusions, lacerations, and cervical strain. 

Emergency Response

At 2:56 p.m., the Monroe (New York) and Ontario (New York) County dispatchers

were notified of the accident through 9-1-1 and initiated the emergency response at 2:57

p.m. Emergency medical personnel and firefighters were on scene by 3:03 p.m. A NYSP

trooper heard the emergency dispatch on his radio and arrived via the eastbound entrance

ramp. Initial calls indicated the accident was at I-90 on the Victor Exit 45 ramp. Within

minutes, the Incident Commander notified the dispatcher of the correct accident location

and access information. 

The first medical flight helicopter was dispatched at 3:03 p.m., and the last patient

was transported from the scene at 4:00 p.m. A school bus transported patients with minor

injuries to another triage center or to local hospitals for treatment.

Approximately 45 NYSP troopers and investigators, including Ontario County

Sheriff’s resources, were dispatched to the scene. About 75 volunteer firefighters and

emergency medical technicians responded from 12 local fire departments and emergency

medical service agencies. The rescue equipment included 17 ambulances, 11 fire vehicles,

and 4 medical response helicopters.

Injury Bus driver Bus passengers Others Total

Fatal 0 5 0 5

Serious 0 7 0 7

Minor 1 34 6 41

None 0 1 3 4

Total 1 47 9 57

Title 49 Code of Federal Regulations 830.2 defines fatal injury as “any injury which results in death within 30 days of

the accident” and serious injury as “an injury which: (1) requires hospitalization for more than 48 hours, commencing

within 7 days from the date the injury was received; (2) results in a fracture of any bone (except simple fractures of

fingers, toes, or nose); (3) causes severe hemorrhages, nerve, or tendon damage; (4) involves any internal organ; or

(5) involves second- or third-degree burns, or any burn affecting more than 5 percent of the body surface.”
Factual 8 Highway Accident Report

Meteorological Information

The National Oceanic and Atmospheric Administration station in Rochester, New

York, about 10 miles west of the accident site, reported clear conditions, a temperature of

87.8o Fahrenheit, and a southerly wind speed of 7 knots at the time of the accident.

Figure 5. Accident bus passenger seating chart. (Seat locations could not be determined for 

six passengers.)

12

1

2

3

4

5

6

7

8

9

10

13

11

M - 59 : M 

F - 52 : M 

M - 59 : M 

M - 41 : M 

F - 57 : M 

M - 66 : M 

F - 43 : M 

F - 56 : M 

F - 27 : M 

M - 32 : M 

M - 27 : M 

F - 19 : M 

F - 34 : M 

F - 16 : M 

M - 14 : M 

M - 10 : M 

M - 08 : M 

F - 26 : S 

F - 11 mos : S 

F - 29 : F 14

F - 18 mos : S 

 F - 19 : M

 F - 53 : S

 F - 49 : M

 M - 52 : M

 F - 40 : M

 M - 08 : M

 F - 31 : M

 M - 35 : M

 M - 39 : M

 F - 26 : M & M - 02 : M (on lap)

 M - 64 : M

 F - 62 : S

 F - 59 : M

 F - 16 : F

 M - 15 : M

 M - 16 : F

 M - 13 : S

 F - 03 : N

 F - 31 : F

 M - 29 : F

International Civil Aviation Organization

Injury Legend

SAMPLE

F = FEMALE M = MALE # = AGE

INJURY LEVEL

AGE

GENDER

F - 14 : Minor

Source: NTSB

N

M

S

F

=

=

=

=

None

Minor

Serious

Fatal
Factual 9 Highway Accident Report

Bus Driver Information

The 59-year-old bus driver held a Connecticut class B commercial driver’s license

(CDL) valid through October 26, 2002. The CDL had a “P” endorsement for passenger

transportation and a “T” restriction for taxicab, service bus, motor vehicle in livery

service, coach, and motorcoach operation. This “T” restriction indicated that as an

endorsed passenger driver, the bus driver had completed a fingerprint and background

check and could transport passengers. The bus driver’s current medical examiner’s

certificate (equivalent of a physical examination card) was issued on September 18, 2001,

and noted that the driver had diabetes and peripheral vascular disease.5

Within 3.5 hours of the accident, a blood specimen was drawn from the bus driver

at the emergency room where he was treated. The laboratory results indicated a blood

glucose level of 141 (normal range: 80-120 mg/dL, levels up to 155 mg/dL are generally

considered “under control” for diabetics). The driver told the NYSP that each morning, as

usual, he took his medications: 30 mg Indur, 500 mg Glucophage, unspecified doses of

Lipitor,6 and another medication for controlling protein in the urine. He also advised the

NYSP that he consumed one mixed drink at a casino on Friday night, June 21, 2002; no

other information was available regarding his diet. The NYSP had the blood samples

drawn by hospital personnel analyzed at the NYSP Western Regional Crime Laboratory in

Olean, New York. Postaccident testing for the presence of 21 drugs, including both illicit

and common licit drugs with known performance-impairing effects, yielded negative

results. The alcohol test results were also negative.

According to the motorcoach driver’s log entries (see table 2), the driver was off

duty for 16.5 consecutive hours before starting the accident day return trip from Niagara

Falls to Waterbury.7 The motorcoach driver told the NYSP that he obtained no nighttime

sleep on the 2 days preceding the accident; he said he had three naps totaling about 4 hours

during the 51-hour period preceding the accident. The hotel’s chambermaid informed the

NYSP that it did not appear that the bus driver’s bed had been slept in. Security videotapes

from the casino showed the driver entering and leaving the casino and gambling in the

interim. In addition, the cab driver who had picked up the bus driver from his hotel around

5:30 p.m. on Saturday and driven him to the casino verified the bus driver’s statement

about going to the casino. Safety Board investigators were unable to obtain additional

information from the bus driver after his initial statements.

5 Peripheral vascular disease causes narrowed or blocked blood vessels in the legs, abdomen, pelvis,

arms, or neck.

6 Indur, or propanolol, is a prescription blood pressure medication; Glucophage, or metformin, is a

prescription diabetes medication; and Lipitor, or atorvastatin, is a prescription cholesterol-lowering medication.

7 Title 49 Code of Federal Regulations (CFR) Part 395.5: The passenger-carrying driver may drive no

more than 10 hours after 8 consecutive hours off-duty. Can no longer drive after being on-duty for 15 hours

after 8 consecutive hours off-duty. Cannot drive after being on-duty 60 hours in 7 consecutive days or 70

hours in 8 consecutive days.
Factual 10 Highway Accident Report

Table 2. Summary of bus driver logbook entries.

Date Time Logbook entry Hours

June 20, 2002 0000-0015 Off duty 0.25

0015-0030 On duty, not driving 0.25

0030-0130 Driving 1.00

0130-0145 On duty, not driving 0.25

0145-0200 Driving 0.25

0200-0215 On duty, not driving 0.25

0215-2130 Off duty 19.25

2130-2145 On duty, not driving 0.25

2145-2230 Driving 0.75

2230-2300 Off duty 0.50

2300-2400 Driving 1.00

June 21, 2002 0000-0200 Driving 2.00

0200-0215 On duty, not driving 0.25

0215-0530 Driving 3.25

0530-0545 On duty, not driving 0.25

0545-0700 Driving 1.25

0700-0715 On duty, not driving 0.25

0715-0845 Off duty 1.50

0845-0900 On duty, not driving 0.25

0900-0915 Driving 0.25

0915-0930 On duty, not driving 0.25

0930-2400 Off duty 14.50

June 22, 2002 0000-1115 Off duty 11.25

1115-1215 On duty, not driving 1.00

1215-1245 Driving 0.50

1245-1700 On duty, not driving

(reportedly napped for about 

3 hours)

 4.25

1700-1715 Driving 0.25

1715-1730 On duty, not driving 0.25

1730-2400 Off duty 6.50

June 23, 2002 0000-1100 Off duty 11.0

1100-1230 On duty, not driving (reportedly 

napped for 45 minutes)

 1.50

1230-1330 On duty, driving short distance, 

and on duty, not driving, at two 

locations (reportedly napped 

for 30 minutes)

 1.00

1330-1500 Driving to time of accident 1.50
Factual 11 Highway Accident Report

Motorcoach Information

The 1998 55-passenger Motor Coach Industries model 102DL3 motorcoach had

an overall length of 45.5 feet and unladed weight of 35,000 pounds. It was equipped with

a Detroit Diesel Corporation Series 60, 6-cylinder, 4-cycle diesel engine, which had a

Detroit Diesel Electronic Controls III electronic control module (ECM),8

 which limited

the engine speed to 70 mph. The motorcoach also had an Allison Transmission model

B500 electronically controlled transmission without a retarder. After the accident, Safety

Board investigators, the NYSP, and a Motor Coach Industries representative reviewed

ECM data that indicated the motorcoach had been driven 231,649.5 miles.9

The coach was equipped with an airbrake system that provided braking to all three

axles and a Bendix Commercial Vehicle Systems DD3 emergency park braking system

that operated on the drive axle. All three axles were equipped with standard S-cam drum

brakes with automatic slack adjusters. During the vehicle examination, push-rod stroke

measurements were taken at all six wheel positions. The left rear drive axle brake

exceeded the maximum allowable stroke by 1/8th inch.10 The brake shoe thickness for all

brakes was measured and found to be within the Federal guidelines.11

The motorcoach was equipped with a TRW automotive power steering system, and

the “steerable” third (tag) axle was permanently placed in the locked position (tires

straight ahead), disabling the steering feature of that axle. The steering wheel rotated

freely and smoothly, and the steering linkage was intact and tight. All six of the

motorcoach tires were Goodyear size 315/80R22.5 tires with “highway type” tread. None

of the tires was flat, and each had normal or near-normal air pressure. The second outer

right tire had an 8-inch cut due to the accident, and the third left and right tires had

irregular wear on the outside edges. The motorcoach sustained damage to the left front

wheel well; abrasive markings were consistent with tire contact during the accident event. 

Wreckage Information 

After departing the roadway, the motorcoach struck the W-beam barrier across the

entire width of the front bumper, resulting in approximately 6 inches of crush damage

rearward. The motorcoach’s ground impact, as it landed, was primarily to its right front

corner and resulted in the front bumper being torn off and the windshield being broken

out. After hitting the ground, the motorcoach rolled onto its right side and slid to its final

rest position on the grassy embankment.

8 The ECM’s primary function was to control fuel flow to the engine; the ECM did not contain active

data pages of speed, rpm, and braking.

9 The Detroit Diesel Electronic Controls III recorded 95,561 miles less than the odometer; most likely,

the Detroit Diesel Electronic Controls III mileage parameter was reset sometime during the life of the coach.

10 Because only one of six brakes was out of adjustment, the vehicle would not be placed out of service

under Federal regulations.

11 Title 49 CFR 396.7(a), Appendix G (1)(a)(6).
Factual 12 Highway Accident Report

As a result of the rollover, the right side of the motorcoach sustained moderate

exterior damage along the right side roof rail. The maximum crush to the right side was

approximately 5 inches along the roofline at the middle of the occupant compartment. Six

of the eight right side emergency exit windows had missing or shattered glazing;12 the left

side windows were intact. The rollover and subsequent contact from passengers caused

damage to the interior overhead light console and the luggage rack. The passenger

compartment space was not compromised. Only the bus driver’s seat was equipped with a

three-point restraint; the passenger seats had no restraints. Several seatbacks were

deflected forward due to passenger contact during the accident.

Highway Information

Highway Design

The accident occurred on eastbound I-90 at milepost 350.9, Victor Exit 45, in

Ontario County. I-90 is classified as an urban principal arterial and in the vicinity of the

accident site, was a divided, two-way, six-lane, paved concrete, limited-access highway.

The roadway’s inside and outside shoulders had 16-inch long, 7-inch wide, and 0.5-inch

deep rumble strips spaced 5 inches apart in both traffic directions. The posted speed limit

was 65 mph with an advisory speed of 30 mph on the Victor Exit 45 ramp. 

Just before the eastbound Victor Exit 45 ramp, the two eastbound lanes expanded

to the north (left) by one travel lane and to the south (right) by one exit lane, resulting in

three travel lanes and one auxiliary deceleration lane in the eastbound direction. The

added left through travel lane continued in the eastbound direction past Victor Exit 45.

The far right lane was the deceleration lane for eastbound traffic; it curved off the

highway’s south side and looped around for highway exiting traffic.

About 1,500 feet east of the Victor Exit 45 ramp was the entrance ramp from I-490,

which became an acceleration lane in the eastbound direction for approximately 460 feet

and then merged into the outside eastbound lane of travel on I-90. The Interchange 45

eastbound exit and entrance ramps and the I-90 eastbound through lanes set the triangular

border for the depressed grassy gore area. A W-beam guardrail system, consisting of

3-inch-long by 2-inch-wide by 28-inch-high metal posts, lined both sides of the entrance

ramp and the west side of the exit ramp.13

Six-inch-wide and 10-foot-long retroreflectorized broken white lines, spaced 30

feet apart, separated the three eastbound traffic lanes. A 6-inch-wide retroreflectorized

solid white edgeline separated the outside shoulder from the eastbound traffic lanes. All

12 Glazing describes glass or other transparent materials used for windows.

13 The barriers met Federal guidelines, as specified in the National Cooperative Highway Research

Program 350 and the American Association of State Highway and Transportation Officials (AASHTO),

Roadside Design Guide, fourth edition.
Factual 13 Highway Accident Report

through lane pavement markings met the lane width requirements specified in the Manual

on Uniform Traffic Control Devices.

14

Victor Exit 45

The Victor Exit 45 deceleration lane’s taper15 began approximately 982 feet before

the theoretical gore point,16 and the deceleration lane reached full width approximately

680 feet from the gore divergence.17 The exit had a paved area between the eastbound

travel lanes and the exit ramp, which was painted with wide white diagonal “crossedhatched” raised thermoplastic lines to indicate it was not a travel portion of the highway

(see figure 3). The exit ramp had a superelevation18 of 2.08 percent; the eastbound travel

approach was at a 2.2 percent upgrade.

Traffic Information

The New York State Thruway Authority records from 1997 to 2001 indicated that 306

accidents, resulting in 48 injuries and 1 fatality, happened between mileposts 348.5 and 353.5

for both eastbound and westbound traffic lanes (the accident occurred at eastbound milepost

350.9). The traffic crash data do not include exact accident locations. According to the New

York State Thruway Authority, the annual average daily traffic count from 1996 through 2001

for both eastbound and westbound traffic lanes between Exits 45 and 46 ranged from 25,219

to 31,870 vehicles (see table 3); trucks accounted for 26.6 percent of the total traffic in 2001.

Table 3. Annual average daily traffic count.

Operations Information

Arrow Line, Inc.

According to the Federal Motor Carrier Safety Administration (FMCSA)

registration, Arrow (U.S. DOT 94517) was an authorized for-hire passenger motor carrier

14 Millennium Edition, 2000, as amended, approved by the Federal Highway Administration (FHWA),

as the National Standard, in accordance with 23 United States Code, Sections 109 (d), 114 (a), 217, 315, 402

(a), 23 CFR 1204.4, and 49 CFR 1.48 (b) (33), and 1.48 (c).

15 The pavement area where a lane is being added or dropped, which “tapers” from a zero to full width, or

vice versa. The Victor Exit 45 lane tapered from zero to full width on the approach to the accident location.

16 The apex or intersecting point of the channeled gore area between the through traffic lanes and the exit lane.

17 The point at which the exit lane pavement begins to separate from the through lanes.

18 The cross slope of a roadway associated with a horizontal curve, that is, the “banking” of a curve.

Year Vehicles per day

1996 25,219

1997 26,040

1998 28,427

1999 29,982

2000 30,788

2001 31,870
Factual 14 Highway Accident Report

headquartered in East Hartford, Connecticut; company operations were coordinated at the

Waterford, Connecticut, terminal. A third terminal was in Milford, Connecticut. At the

time of the accident, Arrow provided charter service and tour service throughout the

United States and Canada. Arrow operated line runs19 and contracted transportation

service for corporate and casino employees20 from its three Connecticut terminals. Arrow

managed 20 buses intrastate and 72 buses interstate and employed 206 drivers, including

74 assigned to intrastate and 132 assigned to interstate operations.21 Arrow’s interstate

operation was primarily in the northeast portion of the United States. Arrow had operated

since 1929, and it became a subsidiary of Coach USA in May 1997. (The Coach USAArrow affiliation was noted on motorcoaches, as seen in figure 6.).

The Arrow safety director and assistant safety director were responsible for driver

recruitment, training, remedial training, and duties not directly related to safety. Arrow did

not have a driver-supervised program under which its Safety Department conducted

structured operation surveillance or random road operation spot checks. During the Safety

Board’s investigation following the accident, Arrow indicated that it was developing a

remedial driver training program and a driver logbook review program and that it intended

to begin a safety meeting program for all drivers. According to Peter Pan Bus Lines, Inc.

19 A line run is scheduled service with specific pick up and stop locations.

20 Often referred to as casino runs, which consist of bus service from the casino parking lot to the

casino. The service operates 24 hours a day, 7 days a week.

21 According to the FMCSA’s postaccident compliance review of Arrow, “drivers are permitted to bid

for charter jobs based on seniority and hour availability at least two weeks prior to the job taking place.”

Figure 6. Coach USA logo on accident motorcoach.
Factual 15 Highway Accident Report

(Peter Pan), the current holding company for Arrow, new drivers are required to train with

a coach from 3 to 7 weeks, remedial driver training does occur, and safety personnel have

been trained to conduct logbook reviews. (See Peter Pan Bus Lines, Inc., section of this

report for more information.)

Coach USA

Coach USA is a holding company22 for bus companies throughout the United

States and is not registered with the FMCSA as a motor carrier. At the time of the

accident, the company was part of Stagecoach Group, an international corporation

headquartered in Perth, Scotland. As a holding company, Coach USA provided a national

network of marketing and advertising, support for safety, and service facilities to maintain

policy uniformity throughout its company affiliates. According to the corporate vice

president of safety, Coach USA was affiliated with the following company operations:

line, taxi, transit, bus service contract, and charter.

According to Coach USA, it did not exercise direct control over the operation of its

affiliate companies. At the time of the accident, Arrow had its own company management

structure and operated as an independent company from Coach USA. During the Safety

Board’s on-scene investigation, Coach USA created the position of Arrow general

manager, whose duties included direct oversight of the three Connecticut terminal

managers; brought in a new vehicle maintenance manager; and acquired computers

equipped with an online driver training program.23

As part of its companywide oversight program, Coach USA contracted Driver’s

Alert, a Florida-based company, to operate a complaint and compliment tracking service.

According to Coach USA officials, Driver’s Alert monitored the Arrow fleet from

February 15, 2002, through November 17, 2002. As of November 17, 2002, Driver’s Alert

received 172 incident reports of driving infractions involving Arrow vehicles; Arrow

responded to 1 incident report. The incidents reported pertained to driver actions such as

weaving, unsafe lane changes, speeding, tailgating, failures to yield and to stop, and faulty

equipment. Of the 172 incident reports, 15 complimentary calls were received.

Each bus exterior in the Coach USA fleet, including the accident bus, was marked

with a unit identification number and a toll-free telephone number for motorists to call and

comment on a driver’s performance.

22 A holding company is usually a corporation that is created to own stock of other corporations and,

thereby, often controls the management and policies of its affiliates.

23 Coach USA reported in May 2004 that all drivers are now trained in basic recognition of drugs and

alcohol and abnormal activity. According to Coach USA, drivers who suspect other drivers of drugs,

alcohol, or other abnormal activity are to notify dispatch and a supervisor. Coach USA does not have a

policy for disciplining a driver for failure to report. 
Factual 16 Highway Accident Report

Driver’s Alert operated as follows:

1. When a complaint was received in which the caller was identified and

provided call-back information, the Coach USA affiliate was notified and that

company’s safety director conducted a followup investigation of the incident;

the safety director then notified Driver’s Alert regarding the complaint. If not

notified within 5 days by the affiliate’s safety director, Driver’s Alert contacted

the Coach USA regional director of safety. Driver’s Alert also provided

monthly summary reports to the notified Coach USA affiliate safety directors.

2. When a complaint was received from a caller, who did not wish to be identified

and provide call-back information, the report was not forwarded to the Coach

USA affiliate. According to a Driver’s Alert representative, experience

indicated little value in processing anonymous calls because the complaint

calls could not be substantiated or resolved without followup information. 

Peter Pan Bus Lines, Inc.

On May 31, 2003, Coach USA sold its Arrow holdings to Peter Pan, headquartered in

Springfield, Massachusetts. Peter Pan continued operating Arrow in a manner similar to that

employed by Coach USA; Arrow functioned as its own company, using the name Arrow.

Peter Pan did not employ Driver’s Alert or any other vendor to provide driver

operational oversight. Peter Pan planned to use an in-house program similar to that used

for the company previously and, also, a satellite tracking system of its vehicles as an

oversight program. Peter Pan had an existing on-board recorder program for drivers, but

did not plan to provide its new subsidiaries with that program, since the fleets will use the

satellite system. Arrow drivers are now part of the Peter Pan drug and alcohol program,

driver files have been reviewed and updated, and Arrow’s management and supervisory

personnel have been replaced.

According to Peter Pan, company policy is that each driver is responsible for the

safe operation of the assigned bus and its passengers. If a driver suspects that another

driver is impaired, the former is required to report the possibly impaired driver to a

supervisor or dispatch, and the supervisor is to respond after notifying the safety director.

A driver can be disciplined, including a suspension, for failing to report a driver who is

suspected of impairment. Only a trained supervisor can evaluate a driver for reasonable

suspicion of drug or alcohol use.24 If a driver reports another driver to the company, either

before the start of a trip or on the road, he or she may do so in person, by telephone, or

anonymously. The informed supervisor is to report to the location of the complaint if it is

away from a terminal.

24 Title 49 CFR Part 382.
Factual 17 Highway Accident Report

FMCSA Compliance Review Program

General. FMCSA standards require a motor carrier to have adequate management

controls in place that comply with applicable safety requirements. The FMCSA uses a

rating formula to determine a motor carrier’s safety fitness. The safety fitness rating

methodology begins with an FMCSA-conducted compliance review,25 applying six factors

(see table 4) that rate the carrier’s compliance with the Federal Motor Carrier Safety

Regulations (FMCSRs).

Table 4. Factors for FMCSA safety compliance.

Factors 1-General, 2-Driver, 3-Operational, 4-Vehicle, and 5-Hazardous Materials

are rated satisfactory, conditional, or unsatisfactory. The ratings are defined below:

• Satisfactory—carrier has not violated any acute regulations or shown a pattern

of noncompliance with critical regulations for that factor.

• Conditional—carrier has violated an acute regulation or had a pattern of

noncompliance with critical regulations.

• Unsatisfactory—carrier has violated two or more acute regulations or has

patterns of noncompliance with two or more critical regulations. 

Factor 6-Accident is rated either satisfactory or unsatisfactory; a conditional rating

is not given.

Acute26 violations of the FMCSRs or hazardous materials regulations are those that

demand immediate corrective action regardless of the motor carrier’s overall safety

posture (for example, requiring or permitting the operation of a vehicle declared out of

service before repairs are made).27 Critical28 violations are regulatory violations that

indicate breakdowns in the motor carrier’s management controls (for instance, requiring

or permitting a driver to drive after having been on duty for 15 hours).29

25 Title 49 CFR Part 385, Appendix A.

Factors Applicable FMCSRs and other criteria

1 – General Parts 387 and 390

2 – Driver Parts 382, 383, and 391

3 – Operational Parts 392 and 395

4 – Vehicle Parts 393 and 396 and out-of-service rate

5 – Hazardous materials Parts 107, 171, 172, 173, 177, 180, and 397

6 – Accident Recordable accident rate

26 Title 49 CFR 385, Appendix B II (b).

27 Title 49 CFR 396.9 (c) (2).

28 Title 49 CFR 385, Appendix B II (b).

29 Title 49 CFR 395.3 (a) (2).
Factual 18 Highway Accident Report

For Factor 4-Vehicle, the carrier’s out-of-service rate is determined by the number

of vehicles placed out of service in relation to the number of vehicles inspected at a

roadside inspection. The number of roadside vehicle inspections is dependent on the

number of vehicles in a carrier’s fleet.30 Only the most recent (the past 12 months in

chronological order) roadside inspections are applied for the out-of-service calculation. If

a carrier’s out-of-service rate exceeds 34 percent and the carrier has a pattern of critical or

acute violations or both, the rating is unsatisfactory. If the carrier’s out-of-service rate

exceeds 34 percent but the carrier does not have a pattern of violations, the rating is

conditional. If the carrier’s out-of-service rate is less than 34 percent but the carrier has a

pattern of critical or acute vehicle violations or both, the rating is conditional. Otherwise,

the carrier receives a satisfactory rating for an out-of-service rate under 34 percent.

For Factor 6-Accident, the recordable accident rate is calculated by multiplying the

number of interstate, reportable accidents for the 12 months before the compliance review

by 1 million and dividing that number by the fleet’s total interstate miles. If a carrier’s

accident rate exceeds 1.5 per million miles for a company that operates over a 100-mile

radius or 1.7 per million miles for a company that operates in less than a 100-mile radius,

an unsatisfactory rating is given. A calculated number under these rates results in the

company receiving a satisfactory rating for this factor.

The rating for the first five factors and the accident rate for the 12 months before

the compliance review are entered into a rating table, which is used to establish the motor

carrier’s safety rating (see table 5). Each of the six factors is given equal weight.

Table 5. Motor carrier safety ratings. 

30 For example, the minimum number of vehicle inspections needed for a motor carrier with 20 vehicles

is five. Based on this example, the five most recent inspections for the past 12 months or since the last

compliance review would be used to calculate the carrier’s out-of-service rate. These inspections may have

been conducted during a roadside inspection or during vehicle inspections conducted at the carrier’s

terminal.

Factor rating Safety rating

Number of

unsatisfactory ratings

Number of

conditional ratings

Resultant safety rating

0 2 or less Satisfactory

0 More than 2 Conditional

1 2 or less Conditional

1 More than 2 Unsatisfactory

2 or more 0 Unsatisfactory
Factual 19 Highway Accident Report

A carrier may be selected for a compliance review if identified as a high-risk

carrier because of (1) a Safety Status Measurement System (SafeStat) score,31 (2) a

complaint against the company, (3) an enforcement followup to ensure that an

enforcement action taken was effective, (4) involvement in a fatal accident, or (5)

involvement in a major hazardous materials accident. 

Arrow. After the accident, the FMCSA conducted a compliance review of Arrow.

The company was issued an overall Conditional safety rating because, of the five

applicable ratings, only Factor 4-Vehicle was Unsatisfactory. According to the FMCSA,

Arrow’s “compliance review revealed non-compliance with the Federal Motor Carrier

Safety Regulations in almost all applicable parts to Arrow Line Inc.’s passenger

transportation operation.” Many violations were driver- and vehicle-related. (Appendix F

provides a table of the Arrow violations.) Arrow received the following ratings:

• Satisfactory for Factor 1-General,

• Satisfactory for Factor 2-Driver Qualification,

• Satisfactory for Factor 3-Operational/Driving,

• Unsatisfactory for Factor 4-Vehicle/Maintenance (40 percent out-of-service

rate for its vehicles),

• Not Applicable for Factor 5-Hazardous Materials, and

• Satisfactory for Factor 6-Crash Rate. 

On July 24, 1994, Arrow had received a compliance review as a result of being

placed on the U.S. Department of Transportation (DOT) Office of Motor Carriers32 “Top

500 Worst Carriers List.”33 Arrow was given an overall safety rating of Conditional, and

the Office of Motor Carriers noted that 25 percent of the checked driver logs were found to

be false.34 As a result of the July 1994 compliance review, Arrow underwent a followup

compliance review on November 21, 1994, and received an overall Satisfactory rating;

Factor 2-Driver and Factor 4-Vehicle were rated Conditional.35

31 The Safety Status Measurement System (SafeStat) analysis program utilizes data from Federal and

State sources, including roadside inspections, accident data, and enforcement actions for all carriers, to

develop a safety fitness assessment of a motor carrier.

32 This agency was the predecessor to the FMCSA.

33 This list is no longer compiled because it had been a project under the previous Selective Compliance

and Enforcement Selection process used by the Office of Motor Carriers to focus on carriers who had high

out-of-service rates based on at least 20 roadside inspections between January and October 1993. When

SafeStat was instituted nationally in 1997, it replaced the Compliance and Enforcement process as the

FMCSA’s primary tool for identifying and prioritizing carriers for compliance reviews.

34 The July 1994 compliance review revealed evidence of noncompliance in the areas of financial

responsibility, driver qualification, driver hours of service, and vehicle out of service. The combination of

noncompliance in these critical areas resulted in a conditional safety rating for Arrow. 

35 The November 1994 compliance review revealed noncompliance in the driver qualification and

vehicle out-of-service areas and resulted in a Satisfactory safety rating.
Factual 20 Highway Accident Report

The last Office of Motor Carriers inquiry into Arrow’s operations prior to the

Victor accident was the result of a complaint to the DOT’s Office of Congressional Affairs

that charged Arrow with violations of the FMCSRs. On October 31, 1995, the DOT

responded that it “would closely monitor Arrow Line vehicle and driver safety

operations.” According to Arrow’s operational history, the company was not given any

compliance reviews, safety ratings, or enforcement followups from 1995 until this

accident. The Office of Motor Carriers did monitor Arrow’s performance through roadside

inspections.

Other Arrow compliance reviews dating back to 1983 indicated that the Office of

Motor Carriers had informed Arrow’s management of FMCSR discrepancies and

recommended corrections. (See appendix B for Arrow’s compliance review dates and

safety rating history.) The discrepancies were in Hours of Service, Vehicle Inspection,

Accident Report Requirements, and Insurance Regulation Requirements. During each

compliance review, the Office of Motor Carriers found that some of the discrepancies

were not corrected after the previous compliance review or safety audit.

Roadside Inspection Program. In the FMCSA roadside inspection program,

qualified safety inspectors carry out roadside inspections in compliance with the North

American Standard Guidelines, which were developed by the Commercial Vehicle Safety

Alliance and the FMCSA. During roadside inspections,36 an inspector examines individual

commercial motor vehicles and their drivers to determine whether they meet the FMCSRs.

Serious violations result in the issuance of driver or vehicle out-of-service orders; out-ofservice violations must be corrected before the affected vehicle or driver can return to

service.

SafeStat

SafeStat is an automated data analysis program developed by the DOT Volpe

National Transportation Systems Center that uses Federal and State information on

roadside inspections, accident data, and enforcement actions for motor carriers to identify

poor performers. SafeStat is not intended to evaluate every motor carrier in the United

States but to identify motor carriers that are high risk so that further inspections or actions

or both can be taken. Data are compiled to develop a composite SafeStat score for a motor

carrier. If data are insufficient (for instance, fewer than three roadside inspections, fewer

than two accidents, or no compliance review), the motor carrier is not scored.37 SafeStat

scores are updated monthly for all interstate carriers and are primarily used by the

FMCSA as guides or indicators for deploying compliance review and roadside inspection

resources. As of February 20, 2004, over 678,000 recorded motor carriers with census

data in SafeStat were actively operating and of those, 30,000 were passenger carriers.

36 Most State roadside inspections are conducted through the FMCSA-administered grant Motor

Carrier Safety Assistance Program.

37 The SafeStat methodology for developing scores can be found at <www.ai.volpe.dot.gov>.
Factual 21 Highway Accident Report

A Safety Evaluation Area (SEA) value approximates the motor carrier’s percentile

rank relative to all other carriers with sufficient data to be assessed within the same SEA.

The system uses up to 30 months of motor carrier safety and normalizing data to develop

measures and indicators in the four SEAs. The higher the SEA value is, the lower the

carrier’s safety status is. For example, an accident SEA value of 80 for a motor carrier

indicates that approximately 80 percent of the carrier population with sufficient data had a

better safety performance than that carrier with respect to the accident SEAs. The four

SEA values (Accident, Driver, Vehicle, and Safety Management) are then combined to

calculate an overall safety status assessment, known as a SafeStat score (see appendix C).

The data used to calculate a SEA value are obtained from compliance reviews,

State-reported commercial vehicle crash data, closed enforcement cases, roadside

inspections, and motor carrier census data. Using the calculated SafeStat scores,38 the

FMCSA assigns carriers into categories A through H. Carriers in category A have the

highest SafeStat scores (between 350 and 550) and thus have the most deficiencies.

Category B carriers have a SafeStat score between 225 and 350, and category C carriers

have a SafeStat score between 150 and 225. Carriers that are deficient in one SEA area are

placed in categories D through G, which are used to prioritize carriers for roadside

inspections. Motor carriers placed in category H have no deficiencies in any SEA. The

FMCSA advised the Safety Board on May 11, 2004, that:

[F]rom a compliance review standpoint,39 the FMCSA makes use of SafeStat

scores through the Motor Carrier Safety Improvement Process (MCSIP) that was

implemented in October 2003. The MCSIP is a process to improve the safety of

SafeStat Category A-C motor carriers through more accurate and timely

identification and monitoring. Briefly stated, high-risk carriers (Category A & B)

are recommended for an immediate compliance review while moderate risk

carriers (Category C) are sent a warning letter and are given up to six months to

improve if available resources do not allow for a more immediate compliance

review.

When the public accesses the SafeStat database, the following caution is displayed:

CAUTION: Please verify important data before relying on SafeStat results.

Inaccurate or out-of-date normalizing data can result in SafeStat results that do not

accurately reflect the motor carrier’s safety status.

The FMCSA Web site for the DOT Volpe National Transportation Systems Center

advises:

Most data used by SafeStat are maintained in the Motor Carrier Management

Information System [MCMIS], the FMCSA central database of all motor carriers

with a U.S. DOT number. While the event data (such as roadside inspection and

38 The overall SafeStat score equals the sum of 2 times the Accident SEA value, 1.5 times the Driver

SEA value, the Vehicle SEA value, and the Safety Management SEA value.

39 According to the FMCSA, compliance reviews occurring outside the MCSIP are not necessarily

based on SafeStat results but are based on focus areas (hazardous materials or passenger carriers) identified

in each State’s safety plan and congressional mandates, such as public complaints and revisiting Conditional

rated carriers.
Factual 22 Highway Accident Report

Compliance Review results in moving violations and crashes) are updated

continuously, some normalizing data (e.g. number of power units) may not be up

to date, particularly if the motor carrier has not recently had a Compliance Review

or submitted an updated form MCS-150. This is especially true for the power unit

information used to calculate the Accident Involvement Measure (AIM) and

Accident Safety Evaluation Area (Accident SEA) value. Inaccurate or out-of-date

normalizing data in MCMIS can result in SafeStat results that do not accurately

reflect the motor carrier’s safety status. Prudent users will verify the accuracy of

the data prior to use and motor carriers should examine and correct their own data

by filing an updated form MCS-150 with FMCSA.

At the time of the accident, Arrow was rated as a category H carrier; sufficient

information was available to calculate a SEA value in three categories (Accident, Driver,

and Vehicle), which had a score below 75, but not in the Safety Management category,

since a recent compliance review had not been conducted. Arrow was not given a SafeStat

score because no rated category resulted in a score over 75. FMCSA inspection records

from 2001 indicate that, prior to the accident, Arrow was subjected to 312 roadside

inspections, resulting in an out-of-service rate of 19.33 percent for vehicles and 0 percent

for drivers. The national average for roadside inspections of out-of-service vehicles and

drivers in 2001 was 23.3 percent and 7.6 percent, respectively. After the accident, on

November 9, 2003, Arrow received a SafeStat score of 210 (SEA scores: Accident-5.08,

Driver-75.99, Vehicle-51.02, and Safety Management-95.67) and was rated a category C

carrier. The SEA scores reflect the results of the postaccident compliance review that

reported Arrow did not provide an efficient safety management program.

DOT Office of the Inspector General Audit Findings

On February 13, 2004, the DOT’s Office of the Inspector General (IG) issued its

report Improvements Needed In The Motor Carrier Safety Status Measurement System40 as

a result of an audit of the FMCSA SafeStat program requested by the Chairman of the

House Transportation and Infrastructure Highways and Transit Subcommittee. The IG’s

office conducted its audit with an “overall objective to determine whether SafeStat

reliably identified high-risk carriers.”41 The resulting report noted that although SafeStat

calculated scores consistent with its design, systemic weaknesses existed both in the

reporting of the State and motor carrier data and in the FMCSA’s correcting and disclosing

of data problems.

The report listed three key sources for the SafeStat calculations:

1. motor carriers’ periodic census reports, 

2. police accident reports on crashes involving commercial vehicles, and

3. State reports on driver and vehicle violations found during roadside safety

inspections.

40 Audit Report Number MH-2004-034.

41 MH-2004-034.
Factual 23 Highway Accident Report

The IG reported that as of January 2003, the FMCSA had recorded 643,90942 active

interstate carriers and lacked updated census data43 for 42 percent of the active carriers.

The audit results indicated that even though carriers had inspections on record, the

recorded values were zero in Vehicles for 11 percent of the carriers and zero in Drivers for

15 percent of the carriers.

The Motor Carrier Safety Improvement Act (MCSIA) of 1999 required interstate

carriers to periodically update their identification reports (census forms), and the IG reported

that in November 2000, the FMCSA promulgated rules requiring the updated census reports

but did not enforce the rules by applying fines. According to the IG report, about 272,000

(42 percent) active interstate carriers had not met the requirement to update data every 2

years.44 The IG found that in January 2003, the carrier’s number of power units (vehicles) or

drivers or both was used to calculate the SafeStat score for at least 74 percent of category A

carriers (the highest risk SafeStat category). As the report noted, when zero values were in

the census data, the SafeStat calculations were invalidated and could result in a carrier with

crashes, including fatal crashes, having no SafeStat value in the Accident rate. The audit

report explained that because the number of drivers and power units are used as a divisor in

the calculations, values cannot be computed using zero or blank data. As an example, the

IG’s office found a carrier that had 21 crashes on record, yet received no SafeStat value in

the Accident rate because the carrier’s power units were recorded as zero.

In addition, the IG reported that, nationwide, underreporting across States for all

crashes involving commercial vehicles varied; some States underreported by 60 percent or

more and others by 20 percent or less. The IG noted an FMCSA report (using November

2002 data) that 1,031 of the 4,853 fatal large truck and bus crashes in the National

Highway Traffic Safety Administration (NHTSA) database were missing from the

SafeStat database. Also, according to the IG’s audit, in fiscal year 2002, the States

reported about 19,000 crashes (20 percent) 6 or more months after the crashes occurred.45

As the report noted, SafeStat calculations attach the greatest weight to crashes (crash

history is associated with future crash risks); however, large gaps exist in how completely

and timely States report crash data. The IG report stated:

[A]s a result of weaknesses in the data reported by the States, SafeStat rankings are

geographically biased against the carriers operating in States that provide more

complete data, while weaknesses in the data provided by carriers can produce errors

in SafeStat calculations and cause some high-risk carriers to be missed.

Since 1999, the public has had free access to SafeStat via the Internet, which makes

information available to those making decisions about and assessing the safety of carriers for

personal or business reasons and to carriers verifying the online data for their companies.

According to the IG’s report, the public has accessed the Web site up to 80,000 times a

42 As of August 2003, the FMCSA recorded 665,646 active motor carriers in SafeStat.

43 Census data included the current number of vehicles and drivers.

44 According to the FMCSA, 20 percent of the carriers who are scored in SafeStat and 10 percent of the

carriers who are in the categories A, B, and C do not have updated data.

45 Crashes occurring in the most recent 6 months are weighted more heavily than those in the previous

7 to 30 months.
Factual 24 Highway Accident Report

month. As a result of its audit, the IG’s office recommended that the FMCSA improve the

quality and quantity of the data because, while SafeStat is sufficient for internal use, its

public dissemination and use require timely and rapid corrective action. The FMCSA has

now posted a more detailed cautionary disclaimer on the FMCSA Web site for SafeStat:

Caution Urged in the Use of SafeStat Data: The States are required to provide

standard, basic information about large truck and bus crashes to FMCSA within

90 days of the crash event, and the results of roadside inspections within 21 days

of inspection. However, the completeness, timeliness, and accuracy of crash data–

and to a lesser extent roadside inspection data–vary from State-to-State.

Accordingly, SafeStat’s ability to accurately and objectively assess the safety

fitness of individual motor carriers may be inconsistent and not conclusive

without additional analysis....WARNING: Because of State data variations,

FMCSA cautions those who seek to use the SafeStat data analysis system in ways

not intended by FMCSA. Please be aware that use of SafeStat for purposes other

than identifying and prioritizing carriers for FMCSA and State safety

improvement and enforcement programs may produce unintended results and not

be suitable for certain uses. FMCSA recommends that all motor carriers

periodically verify the accuracy of their SafeStat data.

Appendix G lists the IG’s recommendations and the FMCSA’s responses and

corrective actions taken to date.

ISS-2

The Inspection Selection System (ISS-2), an FMCSA computer program, was

designed to assist field inspectors with selecting vehicles for inspection by identifying

carriers and vehicles that have a history of unsafe practices and poor safety performance.

The ISS-2 criteria are based on data analysis from the MCMIS, SafeStat ratings, or

PRISM.46 If SafeStat contains insufficient data, the ISS-2 values are based on carrier size

and number of past inspections. The inspector’s ISS-2 inquiry results in one of three

responses: Pass, Optional, and Inspect. Carriers are rated on a 100-point score system: 

1. score of 1 to 49—Pass (no inspection required),

2. score of 50 to 74—Optional (inspection feasible), and 

3. score of 75 to 100—Inspect (inspection warranted).

When an inspector accesses the ISS-2, it displays an inspection value, as well as

the source of the value, such as SafeStat or insufficient data (indicated as lack of SafeStat

data) or PRISM. The ISS-2 also displays a section on the carrier’s violation details, which

compares the carrier’s violation history to the national violation warning threshold47 in

specific categories. Carriers that have a violation history greater than the warning

threshold are highlighted, alerting the inspector to concentrate on or pay close attention to

those items during an inspection process.

46 A Federal and State program that links motor carrier safety fitness to State commercial vehicle

registrations. For more information, access <www.fmcsa.dot.gov/factfigs/Prism.htm>.

47 An FMCSA algorithm using national inspection histories and carrier census information.
Factual 25 Highway Accident Report

At the time of the accident, based on the available SafeStat data, Arrow’s assigned

ISS-2 value was 32, indicating that Arrow’s vehicles had a Pass score. The violation

details indicated that Arrow exceeded the violation threshold warning in the categories of

Brakes, Steering or Frame, and Traffic Laws. After the accident, Arrow’s ISS-2 value was

98, indicating that an inspection was warranted.

U.S. Department of Defense

On February 6, 1986, the Bureau of Motor Carriers (predecessor agency to the

FMCSA) and the U.S. Department of Defense (DoD) Military Traffic Management

Command (MTMC), now known as the Surface Deployment and Distribution Command

(SDDC), signed a Memorandum of Agreement that provided for an exchange of information

and permitted the MTMC/SDDC access to the MCMIS, which contains carriers’ profiles;

accident, enforcement, and inspection histories; and compliance review and safety rating

information. The Memorandum of Agreement is no longer in effect, and the military does

not have direct access to the MCMIS but can access the SafeStat information online.

Prior to 1992, to qualify as a MTMC/SDDC-approved motor carrier for

transporting military personnel, carriers were required to demonstrate they had a DOT

compliance review rating of Satisfactory and had been in operation for over 12 months. A

high failure rate during MTMC/SDDC inspections of motor carriers that had been

previously considered qualified subsequently led to implementation of a

“prequalification” screening and inspection process.

The prequalification inspection is a full on-site compliance review and performance

evaluation. A DoD contractor conducts the inspection, and those carriers receiving a poor

rating, such as 4 or 5,48 are prohibited from transporting military personnel. All motor

carriers who have failed this prequalification inspection are carriers who received an

FMCSA Satisfactory rating and have been operating for longer than 12 months.

After 1992, before undergoing the prequalification inspection, motor carriers had

to pass a DOD contractor-conducted “prescreening” that tested the applicant carriers’

knowledge and understanding of specific regulatory requirements. According to the

MTMC/SDDC contractor,49 even though established motor carriers had applied, not one

motor carrier answered all the compliance questions correctly. About 25 percent of the

motor carriers who applied to the MTMC/SDDC failed the prescreening process, and 40

percent who did pass the prescreening then failed the subsequent prequalification inspection. 

Arrow had undergone DoD contractor-conducted inspections in 1998, 1999, and

2000. Prior to the Victor accident, the most recent inspection was on December 4, 2001, and

resulted in Arrow receiving a rating of 4. The inspection report noted a number of serious

violations and operational deficiencies, which included incomplete driver qualification files

and inadequate preemployment checks. The Vehicle Factor section noted irregularities in

maintenance, repairs, and documentation and noncompliance with driver vehicle inspection

48 The MTMC rating system is based on a scale of 1 to 5, with 1 being the highest and 5 being the lowest.

49 FMCSA Docket No. FMCSA-2001-11061.
Factual 26 Highway Accident Report

reports. In the rating comments, the report recommended that Arrow not be disqualified

because the motor carrier was taking “aggressive” steps to correct the discrepancies. In

addition, the report stated, “[I]t is Coach USA’s responsibility to monitor the managers of

their operating subsidiaries.” Arrow, which was owned and operated by Coach USA, had

done nothing to correct discrepancies noted in past inspections. Neither the DoD contractor

nor the MTMC/SDDC office informed the FMCSA of its findings, nor were they required to

do so. On June 27, 2002, as a result of the Victor accident, the MTMC/SDDC notified Arrow

that the carrier had been placed in a “nonuse” category.

Tests and Research

Accident Reconstruction

The NYSP mapped the accident site in detail and provided the following results.

The physical evidence revealed no braking tire marks on the roadway before the

motorcoach veered off the highway. In the gore area between the mainline and the ramp,

several scuffmarks extended about 120 feet just outside the ramp edgeline. According to

the NYSP measurements, the scuffmarks had a radius of 657 feet. Two distinct parallel

furrowed tire marks, approximately 350 feet long, were on the grassy median that divided

the exit and entrance ramps. According to the NYSP, these tire marks showed that the

motorcoach traveled up the embankment to the entrance ramp and struck the W-beam

barrier at a 90-degree angle on the north side of the ramp. The guardrail became lodged on

the motorcoach; approximately 700 feet of guardrail was pulled from its support posts

onto the entrance ramp. No tire marks were found on the entrance ramp or on the W-beam

guardrail on the south side of the entrance ramp, indicating the motorcoach was airborne

for 63 feet.50 The motorcoach left tire marks on the south side past the entrance ramp,

where the vehicle came to final rest, down the embankment, and next to a guardrail on the

north side of Willowbrook Road (see figure 3).

Accident Simulation

As part of its investigation, the Safety Board simulated the accident using Human

Vehicle Environment System software.51 The simulations were conducted to determine the

dynamics of the accident motorcoach, with emphasis on the motorcoach’s approach to the

exit, the bus driver’s potential steering input, and the motorcoach’s vault and rollover. The

simulations also provided a crash pulse (the forward, lateral, and vertical accelerations for

the motorcoach as it struck the guardrail, vaulted over the eastbound entrance ramp, and

came to final rest). The crash pulse was used to assess accident severity.

50 The NYSP determined that the airborne angle of departure at the embankment was 8 degrees.

51 Version HVE4.4 was released February 6, 2003, by the Human, Vehicle, Environment, Engineering

Dynamics Corporation, Beaverton, Oregon.
Factual 27 Highway Accident Report

To estimate the speed of the motorcoach before it left the roadway, the simulations

utilized road evidence at the accident site, tire marks, impact with the north side guardrail,

and witness accounts. The simulations indicated that at speeds of 60 mph, only two very

short tire marks were present on the roadway. At speeds over 63 mph, the motorcoach

yawed substantially, control of the motorcoach could not be maintained before striking the

guardrail, and the guardrail strike site was substantially to the right of the accident

motorcoach’s actual strike site. The simulation indicated that at the gore area, the accident

motorcoach was probably traveling between 60 and 63 mph.

The simulations showed that the motorcoach most likely drifted to the right, off the

through lanes, and into the gore area for the exit ramp without much substantial steering

(by maintaining a slight right turn similar to that needed to negotiate the curvature of I-90

in the main through lanes before the exit ramp). The bus driver could have maintained the

same steering for about 10.75 seconds while heading towards and entering the gore. The

tire marks on the gore edgeline were made as the steering was increased. The calculations

and the simulations indicated that the motorcoach quite likely vaulted after hitting the

north guardrail on the entrance ramp at about 45 mph and slowed to about 33 mph during

the vault, as it landed.

Motorcoach Crashworthiness in Other Countries

In Europe, directives (regulations) are in place that relate to the strength of the

motorcoach superstructure and seats and their anchorages. Although these directives are not

compulsory,52 motorcoach manufacturers consider them when developing, approving, and

testing new motorcoaches.53 The fitting of motorcoach seat belts in European countries

varies from country to country; the European Union Commission is attempting to make

compliance with the seat belt regulation for new vehicles mandatory throughout Europe.

In January 2000, the European Union Commission initiated a 3-year research

program, “Enhanced Coach and Bus Occupant Safety,” the goal of which was to reduce

injuries through the development of new motorcoach regulations and standards. The

program initially focused on the analysis of motorcoach collision data, and that analysis

was completed in 2001. The results were published in an August 2003 report,54 which

included a suggested list of recommendations for new regulations and written standards

pertaining to motorcoach and bus safety in the areas of rollovers and frontal and rear-end

52 The United Nations’ Economic Commission for Europe details the list of regulations known as the

Geneva Regulations. European countries may adhere in a voluntary manner to each of these regulations,

which will be mandatory in a particular county only if the regulations are explicitly incorporated into the

country’s regulations. The European directives are mandatory for all European Union members when the

directives are included in Directive 70/156-2001/116/CE. Those directives are issued by the European

Parliament Council or European Commission, depending on the case, and they are approved in Brussels.

53 RONA Kinetics and Associates, Ltd., Evaluation of Occupant Protection in Buses, Report RK02-06,

North Vancouver, British Columbia, Canada, June 4, 2002. Prepared for Road Safety and Motor Vehicle

Regulation Transport, Canada.

54 ECBOS - Enhanced Coach and Bus Occupant Safety, Final Published Report, project number 1999-

RD.11130, funded by the European Commission under the Competitive and Sustainable Growth Program of

the 5th Framework, August 2003.
Factual 28 Highway Accident Report

impacts. In addition, the report included recommendations for new regulations pertaining

to the development of rollover dummies, avoidance of partial ejections, contact loads with

side windows or structures, further research on the general rating of passive safety, and a

harmonized accident database. 

In the United Kingdom, regulations have been introduced that require that seat

belts be fitted in all new intercity and mini buses. In one study, 55 detailed data on 47

rollovers revealed that the application of two countermeasures, restraints and retentive

glazing, would have reduced the injury severity for 55 percent of fatally and severely

injured bus occupants. Additional studies have been done to develop a coach seat that

could use a three-point seat belt to restrain the seat occupant, as well as provide effective

occupant protection for an unbelted occupant during a frontal impact.

In late 1994, the European Union Commission began a project on problems related

to seat belt installation in motorcoaches. The concerns included seat size, cost, weight, and

potential injury to an unbelted passenger seated behind the belted passenger. Since 1994,

bus seats with integral seat belts have become available that overcome these concerns.56

These seats passed all tests for conditions of combined loading in which an unbelted or lap

belted passenger impacted the seat in front of the one in which passengers had been belted.

The seat, which is made using conventional materials and production methods, was tested

with standard mounting rails and is no larger and weighs no more than a typical European

production seat currently in use.

In Australia, as a result of severe motorcoach collisions and significant public

pressure, regulations were introduced to address rollover strength, seat and seat anchorage

strength, and the fitting of lap/torso belts for motorcoaches.57 The Australian and

European regulations regarding the strength of the bus superstructure, seat attachments,

and seat belts generally reflect real-world collision data.58

In Canada, every new bus built or imported must comply with the applicable

Canada Motor Vehicle Safety Standards, which currently do not require restraints for

passengers in motorcoaches.

55 P. Botto, M.C. Caillieret, C. Tarriere, C. Got, and A. Patel, “Passenger Protection in Single and

Double-Decker Coaches in Tipping Over,” Thirteenth International Technical Conference on Experimental

Safety Vehicles, Paris, France, 1991.

56 Majid M. Sadeghi, Universal Coach Safety Seat. Paper no. 217 presented at the 18th International

Technical Conference on the Enhanced Safety of Vehicles, Nagoya, Japan, May 19-22, 2003.

57 Report RK02-06, June 2002.

58 Report RK02-06, June 2002.
29 Highway Accident Report

Analysis

In the Victor accident investigation, the Safety Board considered the factors that

may have caused or contributed to the severity of the crash, including the performance of

the driver, the vehicle, and the motor carrier and its holding company; the DOT’s

oversight of motor carrier operations; the highway elements; and the emergency response

and survival aspects. The Safety Board has identified issues regarding the driver’s off-duty

activities and resultant lack of sleep, the motor carrier’s failure to ensure compliance with

Federal regulations, and the DOT’s deficiencies in motorcoach operations oversight, as

well as deficiencies in its rating system for such operations.

In addition, the Board reviewed survival factor and motorcoach crashworthiness

issues similar to those identified in previous accident investigations and in the 1999 Safety

Board report on motorcoach crashworthiness.59 These issues will be discussed in later

sections of this analysis.

Exclusions

The weather was clear and dry at the time of the accident. Postaccident inspection

of the motorcoach did not indicate mechanical problems hindering the vehicle’s operation.

The highway was inspected for design and construction defects in the area of the crash

site. The pavement markings were visible, and no defects in the highway were found that

would have caused or contributed to the crash.

Results of the toxicological analysis of the bus driver’s blood and urine specimens

were negative for alcohol and illicit drugs. The driver was diabetic, and he was taking the

medication metformin, typically prescribed to regulate blood glucose levels. When the

driver was evaluated in the emergency room following the accident, his blood glucose

level was moderately high but was consistent with his treatment for diabetes, indicating no

impairment at the time of the accident.

The initial 9-1-1 call misidentified the exact site of the accident due to the

motorcoach’s location over a steeply sloped embankment; however, the misidentification

did not hamper the emergency response. Appropriate resources were dispatched,

responders and medical personnel arrived quickly to the scene, and the injured received

medical care on scene and were transported to local hospitals in a timely manner.

59 National Transportation Safety Board, Bus Crashworthiness Issues, Highway Special Investigation

Report NTSB/SIR-99/04 (Washington, DC: NTSB, 1999).
Analysis 30 Highway Accident Report

The Safety Board concludes that the weather, the design and condition of the

roadway, the mechanical condition of the motorcoach, and the driver’s diabetes did not

contribute to the accident. Further, test results showed no evidence of drug or alcohol use

by the driver, and the emergency response was adequate.

Accident Discussion

After departing the right side of the roadway, the motorcoach struck the rear of the

W-beam guardrail for the eastbound entrance ramp, vaulted the entrance ramp while

dragging a 700-foot section of the guardrail that then struck three vehicles on the ramp,

collided with the embankment on the far side of the ramp, and finally rolled over onto its

right side and slid to rest. The motorcoach’s initial speed leaving the travel lanes was

calculated based on tire marks and other evidence at the scene. The Safety Board’s

simulations showed that the vehicle’s speed was between 60 and 63 mph in the gore area

where tire marks were found. The posted speed limit on I-90 was 65 mph.

The bus driver did not have control of the motorcoach before the accident, which

resulted in the motorcoach traveling off the right through lane of the highway into the

paved area between the travel lanes and the Exit 45 ramp. Several factors indicate that the

driver fell asleep while operating the motorcoach before it left the roadway. The driver had

obtained no nighttime sleep and only three brief naps totaling less than 4 hours in the 51

hours preceding the accident; he admitted to spending his off-duty hours gambling in a

casino. Although the driver had sufficient time off before the accident trip to comply with

Federal hours-of-service rules, he did not use this time to rest.

The bus driver would not speak to Safety Board investigators; therefore,

determination of the cause of his loss of control at Exit 45 is based on passenger

statements, reports about the driver’s lack of sleep prior to the accident trip, and physical

evidence in the roadway. Before departing Canada, passengers noted the driver napping as

they loaded their luggage. A witness driving behind the motorcoach reported the vehicle

drifting and swerving in the lane and traveling erratically, slow and then fast. During the

trip, passengers described the bus driver rubbing his eyes and resting his chin in his hands

as he drove with his elbows; they stated that the motorcoach often drifted to the right side

of the roadway and over the rumble strips along the shoulder before correcting back into

the travel lane. Unlike the right lane’s shoulder before the exit lane for Exit 45, just prior

to the thermoplastic striped gore area where the motorcoach departed the roadway, the

road surface did not have rumble strips. Therefore, when the driver fell asleep, he did not

drive over any rumble strips that might have awakened him before entering the gore area,

as he had during his earlier episodes of drifting. 

The bus driver’s action exiting the paved roadway onto the gore area was probably

not an intended maneuver. Passengers had observed the driver just prior to the accident

and reported behaviors, such as irritability, restlessness, and lack of concentration, that are

highly indicative of a person experiencing a severely sleep-deprived state. Passengers said

that after the bus driver drifted out of the travel lanes near Exit 45, a passenger cried out
Analysis 31 Highway Accident Report

and then the bus driver “shook his head and grabbed the steering wheel with both hands.”

The passenger may have startled the driver; one problem with a startled response (whether

associated with sleep onset or just a redirection of attention) is that the actions that follow

it are typically without conscious decision or deliberate control.60 The driver’s drifting off

the roadway and traveling over the thermoplastic striping of the gore area suggest that he

had been nodding off, which he had done several times previously during the trip. In this

particular instance, however, a passenger screamed, and thus the driver was possibly

awakened by the noise, observed the exit ramp, and attempted to steer toward it as a

reactive measure rather than a decisive maneuver. This steering maneuver may have also

been part of the wakening response to the passenger’s crying out, irrespective of any

visual input from the exit ramp.

When individuals awaken from Stage 1 sleep (the first stage people enter as they

transition from wakefulness to sleep), they frequently experience some degree of mental

confusion and vague or fragmented imagery.61 This effect is greatest when the person is

sleep-deprived, as was the accident driver, and may explain why he perhaps saw the exit

but was not able to rationally judge its proximity, in the context of the motorcoach’s speed,

before his motor response initiated and the motorcoach left the roadway.

Many individuals also experience hypnic myoclonia, a muscle contraction that can

be local (one limb) or generalized (whole body). This response does not suggest any sort

of sleep pathology; it often occurs when individuals are sitting upright and suddenly their

entire body, or head, jerks as they transition from being awake to sleep. The bus driver’s

abrupt right steering maneuver off the roadway might have been a consequence of hypnic

myoclonia, either directly (muscles in his right arm contracted, causing him to steer to the

right) or indirectly (a generalized response might have challenged his sense of

equilibrium, triggering a reaction that resulted in the rightward steering maneuver).62

Therefore, the Safety Board concludes that the accident bus left the roadway as a result of

the driver falling asleep.

Bus Driver Performance

Off-Duty Hours

The accident driver’s schedule for the 2 days preceding the accident trip included

no driving except for one trip to the local Marineland attraction. Although the driver had a

nighttime travel schedule from Waterbury to Niagara Falls, he had sufficient off-duty time

from his arrival in Niagara Falls on Friday, June 21, about 7:30 a.m., through Saturday,

June 22, at 11:00 a.m. (the departure time for Marineland) to obtain sleep. Furthermore,

60 Mary A. Carskadon and William C. Dement, “Normal Human Sleep: An Overview,” in M.H. Kryger,

T. Roth, and W.C. Dement, [eds.], Principles and Practices of Sleep Medicine, Third Edition (Philadelphia,

PA: W.B. Saunders Company, 2000).

61 Carskadon and Dement.

62 Carskadon and Dement.
Analysis 32 Highway Accident Report

the driver had no driving scheduled from Saturday at 4:30 p.m. (the return time from

Marineland) until Sunday, June 23, at 11:00 a.m. (the departure time for Waterbury) and

therefore had adequate time to obtain additional sleep.

Yet, according to the bus driver’s statement to the NYSP, he had no nighttime sleep

on either of the 2 days preceding the accident. The bus driver’s statements were supported

by security videotapes that showed his arrival at and departure from a local casino in

which he spent his off-duty hours and by the statements from the taxicab driver who drove

the bus driver from the hotel to the casino. In addition, the hotel chambermaid told the

NYSP that the bus driver’s bed did not appear to have been slept in during the bus driver’s

2-night stay. Passengers reported that the bus driver napped during the time when they

were loading their luggage on the motorcoach, and they described his demeanor at other

times as restless and irritable. Passengers also stated that during the return trip just before

the accident, the driver’s behavior indicated that he was sleepy; he was consistently

rubbing his face and arms and resting his elbows on the steering wheel while driving.

Even though the need for sleep varies among individuals, losing as little as 2 hours

sleep can negatively affect alertness and performance, resulting in degraded judgment,

decision making, and memory; slowed reaction time; lack of concentration; fixation; and

irritability.63 The amount of sleep the driver obtained prior to the accident was clearly

insufficient to meet the physiological need for sleep; the bus driver reported taking three

brief naps, totaling 4 hours of sleep, in the 51-hour period before the accident. The bus

driver’s ability to fall asleep “on demand” while awaiting the return of passengers visiting

attractions or the passengers loading their luggage in the motorcoach is further indication

of inadequate sleep. A sleep latency64 of less than 5 minutes is widely regarded within the

sleep medicine community as an indication of a compelling physiological need for

sleep.65, 66

Witnesses stated that the motorcoach drifted in its lane and almost collided with

other vehicles on the highway. Passengers described the driver as consistently drifting

onto the rumble strips of the right shoulder before redirecting the motorcoach onto the

roadway and once almost hitting a parked truck. Although the driver denied falling

asleep at the time of the accident (he stated that he had the habit of stretching; rubbing

his head, chin, and neck; and squirming in his seat when driving), the onset of sleep is

subtle and may not be apparent to the individual experiencing the first stage of sleep.

Research on sleep deprivation has concluded that the absence of behavioral and

subjective indicators of sleepiness is not always an accurate reflection of the

63 Fatigue Resource Directory Web site <http://www.olias.arc.nasa.gov/zteam/fredi/home-page.html>.

Compiled in conjunction with the NASA/NTSB symposium, “Managing Fatigue in Transportation:

Promoting Safety and Productivity,” and managed by the DOT. Also, Medical Dictionary Web site

<http://www.graylab.ac.uk/omd/contents/F.html>.

64 The amount of time needed to fall asleep.

65 J. Van den Hoed, H. Kraemer, and C. Guilleminault, “Disorders of Excessive Somnolence

Polygraphic and Clinical Data for 100 Patients,” Sleep Vol. 4 (1981).

66 F. Zorick, T. Roehrs, and G. Koshorek, “Patterns of Sleepiness in Various Disorders of Excessive

Daytime Somnolence,” Sleep Vol. 5 (1982).
Analysis 33 Highway Accident Report

physiological state of sleepiness.67 Individuals can often mask symptoms of sleepiness

and even compensate for impaired performance for discrete periods of time; nonetheless,

the inability to maintain wakefulness, even when instructed (or required) to do so, is a

telling indicator of severe sleep deprivation.68

The bus driver purposely used his off-duty time to pursue other activities that did

not include acquiring adequate sleep. Because the driver’s actions were knowing and

deliberate (he gambled in a casino during the night in lieu of sleeping), they were clearly

imprudent. Historically, the Safety Board has recognized that the root cause of many

fatigue-related accidents stems from practices that are administratively controllable by the

motor carrier, such as scheduling. Recommendations directed at motor carriers or entities

that regulate them have emphasized the need to respect the physiological need for sleep in

the establishment of drivers’ schedules, the elimination of incentives or sanctions that

promote drowsy driving, and the education of drivers with regard to sleep hygiene and

safety.69 However, in this accident, the trip itinerary did not include excessive hours for the

driver that would have prevented him from obtaining sleep. The circumstances of this

accident deviate from the usual fatigue-related accidents investigated by the Safety Board

because the motorcoach driver’s lack of sleep was directly attributable to his off-duty

activities and independent of any work-related demands caused by the carrier. The Safety

Board concludes that the bus driver had less than 4 hours of interrupted sleep in a 51-hour

period as a result of deliberately spending his off-duty hours in a casino; he was therefore

severely fatigued at the time of the accident. 

Operator Fatigue

The Safety Board has previously addressed the issue of operator fatigue and the

need to provide operators with fatigue awareness training in all modes of transportation. In

1989, the Safety Board issued the following recommendation to the DOT:70

I-89-02

Develop and disseminate education material for transportation industry

personnel and management regarding shift work; work and rest schedules;

and proper regimes of health, diet and rest.

67 K.M. Hartse, T. Roth, and F.J. Zorick, “Daytime Sleepiness and Daytime Wakefulness: The Effect of

Instruction,” Sleep Vol. 5 (1982). 

68 K.M. Hartse, T. Roth, and F.J. Zorick.

69 NTSB/HAR-00/01 and NTSB/SIR-99/01.

70 National Transportation Safety Board, Head-End Collision of Consolidated Rail Corporation Freight

Trains UBT-506 and TV-61 Near Thompsontown, Pennsylvania, on January 14, 1988, Railroad Accident

Report NTSB/RAR-89/02 (Washington, DC: NTSB, 1989).
Analysis 34 Highway Accident Report

A 1999 Safety Board special investigation report71 noted the extensive efforts

made by most of the modal administrations to develop and disseminate educational

materials on fatigue issues and health and diet issues; Safety Recommendation I-89-02

was therefore classified “Closed–Acceptable Response” on May 25, 2001. 

The Board issued Safety Recommendations H-90-21 and H-95-5 pertaining to

driver fatigue in commercial motor vehicles to the FHWA urging that educational

materials be developed for commercial drivers about the dangers of driving while drowsy.

According to the FHWA, the agency’s goal was to educate all CDL holders on recognizing

fatigue and on the importance of adequate rest and healthy work and lifestyle choices. The

Safety Board commended the FHWA for working with different organizations to educate

drivers about the dangers of drowsy driving, and Safety Recommendations H-90-21 and

H-95-5 were classified “Closed–Acceptable Action” on July 7, 1998.

In February 1999, the Safety Board recommended in its special investigation

report, Selective Motorcoach Issues, that the DOT:

H-99-4A

Require that the Federal Highway Administration’s fatigue video that is being

developed for motorcoaches discuss the dangers of inverted sleep periods.

In June 1999, the FHWA began a two-phase project addressing bus driver fatigue. In the

first phase, the FHWA studied the differences between motorcoach operations and truck

operations as they related to operator fatigue. In the second phase, the FHWA developed a

fatigue awareness and countermeasure video for motorcoach drivers, which was

distributed to the industry in February 2000. The Safety Board reviewed the video and, as

a result, classified Safety Recommendation H-99-4A “Closed–Acceptable Action” on

December 7, 2000.

Increased awareness and recognition of the dangers of drowsy driving are essential

to reduce this threat to transportation safety. The circumstances of this accident indicate

that the accident driver took no personal responsibility for being well rested and fit for

duty. The accident driver was charged and subsequently convicted of manslaughter,

assault, reckless driving, and reckless endangerment.72

The prevention of future accidents requires measures to promote drivers’

acceptance of personal responsibility for their off-duty actions that are beyond the purview

of their employers, and the emphasis on personal responsibility to be fit for duty should be

included in the training given by motor carriers. The Safety Board will inform the

Amalgamated Transit Union, United Transportation Union, American Bus Association,

71 National Transportation Safety Board, Evaluation of U.S. Department of Transportation Efforts in

the 1990s to Address Operator Fatigue, Special Investigation Report NTSB/SIR-99/01 (Washington, DC:

NTSB, 1999).

72 The driver pled guilty and received the maximum sentence permitted under New York State law (3

years and 4 months to 10 years).
Analysis 35 Highway Accident Report

and United Motor Coach Association of the circumstances of this accident and the driver’s

failure to manage his off-duty activities in a manner that ensured his fitness to drive,

emphasizing that drivers need to use discretion in planning their off-duty activities and

need to obtain adequate sleep.

Driver’s Alert Program

The trip coordinators and several motorcoach passengers expressed concern over

the accident bus driver’s visible sleepiness. Even without knowing that the driver had been

awake for nearly 2 days, the coordinators recognized that the driver was unfit to perform

his duties, since he displayed obvious signs of a sleep-deprived state. Initially, they sought

the assistance of the motorcoach 2 driver, who knew of the accident driver’s overnight

casino trips and yet deferred to the accident driver’s statement that he was “okay to drive.”

The motorcoach 2 driver told the NYSP that the accident bus driver had “30 years

experience and would know if he was alright.” During the trip, a coordinator used the

microphone, speaking in Spanish, to tell the passengers that they should make noise

because the driver was sleepy. Another passenger approached the driver just prior to

Victor Exit 45 and asked him to pull over at the next stop and rest; however, the driver

rebuffed her and she started to return to her seat.

In 1998, the Safety Board investigated an accident near Burnt Cabins,

Pennsylvania,73 in which the bus driver fell asleep and the motorcoach ran off the road,

striking a parked semitrailer. Greyhound Lines, Inc. (Greyhound), which owned the

motorcoach, had a 1-800-SAFEBUS driver safety check program that included a written

policy for processing complaints against drivers, similar to the Driver’s Alert program for

Coach USA. The purpose of the 1-800-SAFEBUS program was to allow the public to

report to the company, using a toll-free number, on driver performance, service, and

driving behavior. As in the Driver’s Alert program, the number was displayed on the

outside of the Greyhound motorcoach and the system did not process anonymous calls. As

a result of its investigation, the Safety Board concluded that Greyhound’s policy of

disregarding anonymous calls prevented the company from identifying patterns of unsafe

driving practices by particular drivers or on particular runs and diminished the safety

oversight benefits of the program. As a result, the Safety Board issued the following

recommendation to Greyhound:

H-00-9

Revise your 1-800-SAFEBUS program to ensure that all complaints are

included in drivers’ files and used in drivers’ assessments.

In September 2000, Greyhound responded that after an analysis of the SAFEBUS

program, Greyhound agreed to perform a case-by-case review of anonymous motorist

complaints. The anonymous calls would no longer be discarded by the SAFEBUS vendor

73 National Transportation Safety Board, Greyhound Motorcoach Run-off-the-Road Accident, Burnt

Cabins, Pennsylvania, June 20, 1998, Highway Accident Report NTSB/HAR-00/01 (Washington, DC:

NTSB, 2000).
Analysis 36 Highway Accident Report

and would be passed on the to the Greyhound Safety Department for further action. The

Safety Board therefore classified Safety Recommendation H-00-9 “Closed–Acceptable

Action” on January 5, 2001.

In the Victor accident, the exterior of the accident motorcoach also displayed a

toll-free number for individuals to call when they observed the motorcoach being operated

in an unsafe manner. The Coach USA Driver’s Alert Program operates 24 hours a day and

is staffed by personnel who speak directly with the caller and obtain information.

Although another driver reported to the NYSP after the accident that the bus driver had

been driving erratically, no calls to Driver’s Alert were made prior to the accident. Quite

possibly, even if calls had been made to report the accident driver, had the callers

remained anonymous or been unwilling to leave contact information, nothing would have

been done to investigate the complaint and stop the driver. The Safety Board concludes

that even if passengers had called Driver’s Alert to report the driver, a system was not in

place to allow Arrow to take immediate action. Although Coach USA no longer owns

Arrow, Coach USA owns many subsidiary passenger carriers and still uses the Driver’s

Alert program. The Safety Board believes that Coach USA should evaluate all calls

reporting dangerous driver behaviors immediately upon receiving them and establish a

method to reach the driver so that Coach USA can evaluate the driver’s fitness for duty

and take appropriate countermeasures, if necessary. 

During interviews, the passengers indicated obvious concern regarding the driver’s

state; yet, either the passengers did not recognize the seriousness of the situation, or none

were able to identify an option to promptly obtain the driver’s cooperation in delaying or

discontinuing the trip until he had obtained sufficient rest. After having approached the

accident bus driver’s colleague and after futilely requesting his assistance with the

fatigued driver, several passengers felt helpless during the events that led up to the

accident and seemed reluctant or felt unable to take control of the increasingly dangerous

situation. Although many passengers aboard the motorcoach used their cellular telephones

to call relatives and friends after the accident, none used the cellular telephones before the

accident to report the driver or situation to 9-1-1. Instead, the passengers deferred to the

driver’s authority and let the trip continue.

In a motorcoach, the driver is normally in charge, which in most situations is the

most appropriate allocation of authority. When a driver is impaired, whether due to fatigue,

intoxication, or an apparent medical condition, passengers are placed at risk. But individuals

may be reluctant to challenge a driver’s fitness for duty directly, particularly if the driver is

irritable or defensive or simply refuses to postpone the trip or to pull over. In this accident,

passengers approached the motorcoach 2 driver, asked for his assistance, and subsequently

deferred to his opinion that the accident driver was fit to operate the motorcoach.

Although the exterior of the accident motorcoach displayed an emergency number,

no similar posting was available inside the bus for passengers to use when they observed

the bus driver operating the motorcoach in an unsafe manner. An emergency number

posted inside the motorcoach may have prompted the passengers to call and report the bus

driver’s behavior. The Safety Board concludes that had Arrow provided a method for

passengers to contact the company to report the driver’s severely fatigued condition, the
Analysis 37 Highway Accident Report

company could have prevented the driver from beginning or continuing the accident trip.

Emergency situations can occur at any time and on any passenger carrier’s motorcoach.

Therefore, the Safety Board believes that the FMCSA should require the posting of an

emergency telephone number on the interior of motorcoaches for passengers to call in the

event of an emergency with the driver. 

Peter Pan Bus Lines currently owns Arrow and does not use Driver’s Alert or any

other vendor for driver operational oversight. The company has a similar in-house

program and plans to use satellite tracking systems as its driver oversight program in the

near future. However, such programs still do not give passengers the ability to contact the

company when they are experiencing an emergency situation with their driver. The Safety

Board will inform the United Motorcoach Association and the American Bus Association

of the circumstances of this accident and of the opportunity to provide passengers, via a

posted emergency telephone number on the interior of motorcoaches, with a readily

available method for communicating directly with companies to report an emergency or

hazardous condition with a driver or vehicle. In addition, the Safety Board will emphasize

to the association the importance of the telephone operator being able to evaluate all calls,

including those from anonymous callers, and the importance of the company establishing

a method to reach the driver to assess the driver’s fitness for duty and, if necessary, take

appropriate countermeasures.

Passengers had approached the motorcoach 2 driver and asked his assistance in

dealing with the fatigued accident bus driver. When the motorcoach 2 driver deferred to

the accident driver’s “Yes, I’m fine” statement, he abdicated his responsibility for the

safety of the accident coach’s passengers. Even though the motorcoach 2 driver was aware

of the off-duty activities of the accident driver and his lack of sleep, he did nothing to

prevent the accident driver from transporting passengers in an unfit state. Failing to report

an on-duty driver who is severely fatigued is no different from failing to report an on-duty

driver who has knowingly been drinking or using drugs.74 The motorcoach 2 driver had

spoken with the accident driver, who informed the motorcoach 2 driver of his off-duty

gambling activities during the previous 2 nights; had witnessed the accident bus driver’s

napping onboard the motorcoach during the daytime trip to Marineland; and had observed

the accident bus driver return from the casino and subsequently nap onboard the

motorcoach before departing for the return trip to Connecticut. In spite of his awareness of

the accident driver’s failure to obtain adequate sleep, the motorcoach 2 driver showed a

lack of due concern for the accident motorcoach passengers’ safety. Therefore, the Safety

Board concludes that the driver of the second Arrow motorcoach did nothing to prevent

the severely fatigued accident driver from transporting passengers in his impaired

condition. 

74 Laboratory research has clearly established the relationship between sleep loss, both acute and

cumulative, and decreased performance and alertness. Recently, varying amounts of acute sleep loss (2, 6,

and 8 hours) were found to increase sleepiness more than ethanol and had comparable effects to ethanol on

degrading psychomotor performance. In this study, 4 hours of sleep loss equated to a 0.095 percent BrEC

percent or the equivalent of ingesting five to six 12-ounce beers. See T. Roehrs, E. Burduvali, A. Bonahoom,

et al: “Ethanol and Sleep Loss: A ‘Dose’ Comparison of Impairing Effects,” Sleep, 2003; 26: 981-5.
Analysis 38 Highway Accident Report

Coach USA was the parent company of Arrow at the time of the accident. Coach

USA’s policy now is to train its drivers in the basic recognition of drugs and alcohol, as

well as abnormal activity. Coach USA believes that if an incident between drivers similar

to the one that occurred in the Victor accident were to happen again, another driver would

recognize that a problem exists and would contact dispatch and his or her supervisor.

However, Coach USA does not have a policy for disciplining a driver for failing to report

another driver.

Current Peter Pan policy requires a driver to report the impairment of another

driver due to drugs, alcohol or fatigue to a supervisor or dispatcher, and a supervisor is to

respond after notifying the safety director. A driver is to be disciplined, including

suspension, for failing to report an impaired driver. According to Peter Pan, it has an open

door policy under which the safety director and supervisory personnel are to be notified

either in person or by telephone. Should a report on an impaired driver be received, a

supervisor is to respond directly to the motorcoach’s location. In the Victor accident, such

a report by motorcoach driver 2 might have prevented the accident driver from beginning

or continuing the trip.

The Safety Board will inform the United Motorcoach Association and the

American Bus Association of the opportunity for passenger-carrying operators to provide

their drivers with basic training in the recognition of impairment due to drugs, alcohol, or

fatigue and with a readily available method for communicating directly with supervisory

personnel to report another driver’s impairment so that the motorcoach operator can

evaluate the reported driver’s fitness for duty and, if necessary, take appropriate

countermeasures.

Whenever an accident occurs in which inadequate company oversight of safety

practices may have been a contributing factor, the Safety Board investigates how

corporate culture may have set the stage for the accident.75 Corporate culture can be

described in various ways. One definition refers to it as “the beliefs held by workers and

managers in the organization about the way operations ought to work; the practices and

customs that have become the norm; and, how these various factors are valued either

75 (a) National Transportation Safety Board, Downeast Airlines, Inc., DeHailland DHC-6-200, N68DE,

Rockland, Maine, May 30, 1979, Aviation Accident Report NTSB/AAR-80/05 (Washington, DC: NTSB,

1980); (b) National Transportation Safety Board, Air Illinois Hawker Siddley, HS748-2A, N748LL,

Pinckneyville, Illinois, October 11, 1983, Aviation Accident Report NTSB/AAR-85/03 (Washington, DC:

NTSB, 1985); (c) National Transportation Safety Board, Collision of Northeast (METRA) Train and

Transportation Joint Agreement School District 47/155 School Bus at Railroad/Highway Grade Crossing,

Fox River Grove, Illinois, October 25, 1995, Highway Accident Report NTSB/HAR-96/02 (Washington,

DC: NTSB, 1996); (d) National Transportation Safety Board, Washington Metropolitan Area Transit

Authority Train T-111 With Standing Train at Shady Grove Passenger Station, Gaithersburg, Maryland,

January 6, 1996, Railroad Accident Report NTSB/RAR-96/04 (Washington, DC: NTSB, 1996); (e)

National Transportation Safety Board, Head-On Collision Between Burlington Northern Railroad Freight

Trains 602 and 603, Ledger, Montana, August 30, 1991, Railroad Accident Report NTSB/RAR-93/01

(Washington, DC: NTSB, 1993); (f) National Transportation Safety Board, Highly Volatile Release From

Underground Storage Cavern and Explosion Mapco Natural Gas Liquids, Inc., Brenham, Texas, April 7,

1992, Pipeline Accident Report NTSB/PAR-93/01 (Washington, DC: NTSB, 1993); and (g) National

Transportation Safety Board, Explosion and Fire on Board the U.S. Tankship OMI Charger at Galveston,

Texas, October 9, 1993, Marine Accident Report NTSB/MAR-94/04 (Washington, DC: NTSB, 1994).
Analysis 39 Highway Accident Report

positively or negatively.”76 If an employee’s operating performance conforms to carrier

procedure or reflects the accepted values and attitudes found in the carrier’s workplace

and an unsafe situation occurs, the corporate culture may be at fault.

In the case of Arrow, the company’s history of repeatedly violating FMCSRs

pertaining to passenger safety, particularly in drivers’ false duty logs, hour of service, and

vehicle maintanence, and its failure to prioritize the correction of these violations over 2

decades of operation are evidence of a corporate culture that fostered indifference to

passenger safety. For example, in Arrow’s postaccident compliance review, the driver of

motorcoach 2 was specifically cited as having violated the FMCSR pertaining to false

duty status record reports only 1 month prior to the Victor accident. However, either

Arrow did not address the violation by disciplining motorcoach driver 2 or did not

discover the violation. Both situations demonstrate that Arrow did not have effective

safety management controls. Transportation companies can, through their actions,

communicate to their employees an attitude that influences the degree to which employees

comply with operating rules and with safe operating practices. Corporate culture is

important in every mode of transportation, and it can have influence in even minor ways.

While common sense alone should have prompted the accident bus driver to acquire

adequate sleep before driving, the lack of sleep is not specifically addressed in Federal

regulations, which only require that the driver have adequate time off duty. Nonetheless,

the intent of the regulations is to provide the opportunity to acquire adequate sleep.

Although the driver did not technically violate the hours-of-service rules, he is required to

be “fit for duty.”77 Based on Arrow’s repeated history of failing to correct violations in

hours of service and duty logs among its drivers, it is apparent that the culture prevalent at

Arrow was that adherence to the FMCSRs78 for passenger safety was not a top priority. As

stated in the FMCSA’s postaccident compliance review, Arrow “revealed noncompliance

with the Federal Motor Carrier Safety Regulations in almost all applicable parts to Arrow

Line, Inc.’s passenger transportation operation.” Even before the accident, according to

the MTMC/SDDC 2001 compliance audit report of Arrow, a number of “serious

violations and operational deficiencies [were] found during the review” and “significant

breakdown in the carrier’s safety management controls” was revealed. The audit report

also noted:

76 Remarks of Chairman Jim Hall, National Transportation Safety Board, Symposium on Corporate

Culture and Transportation Safety, April 24, 1997, Washington, DC.

77 Title 49 CFR Part 392.3:

No driver shall operate a commercial motor vehicle, and a motor carrier shall not require

or permit a driver to operate a commercial motor vehicle, while the driver's ability or

alertness is so impaired, or so likely to become impaired, through fatigue, illness, or any

other cause, as to make it unsafe for him/her to begin or continue to operate the

commercial motor vehicle. However, in a case of grave emergency in which the hazard to

occupants of the commercial motor vehicle or other users of the highway would be

increased by compliance with this section, the driver may continue to operate the

commercial motor vehicle to the nearest place at which the hazard is removed.

78 In areas such as hours of service, vehicle inspections, accident report requirements, and insurance

regulation requirements.
Analysis 40 Highway Accident Report

Whenever an audit is conducted, if violations and operational deficiencies are

brought to the carrier’s attention, it is expected that they will take decisive and

immediate corrective action to prevent future violations. When similar violations

or operational deficiencies are again found during any subsequent audits, it has

the appearance that the carrier has either chosen to ignore the violations or failed

to take any initiative to address the concerns. 

Arrow’s management thus fostered the impression that corporate practices did not need to

give priority to passenger safety. Therefore, the Safety Board concludes that at the time of

the accident, Arrow had a documented history, as evidenced in FMCSA compliance

reviews, of failing to adequately oversee operational safety issues and failing to correct

inherent safety problems. 

Motor Carrier and Federal Regulations

U.S. Department of Defense

On February 6, 1986, the Bureau of Motor Carriers (predecessor agency to the

FMCSA) and MTMC/SDDC signed a Memorandum of Agreement that provided

information and granted the MTMC/SDDC access to MCMIS, which contains a carrier’s

profile, accident history, enforcement inspection history, and compliance review and

safety rating information. Arrow underwent inspections by the DoD’s contractor in 1998,

1999, 2000, and 2001. The most recent inspection was on December 4, 2001, and resulted

in a low rating of 4. The executive summary of the inspection report noted a number of

serious violations and operational deficiencies. Neither the DoD contractor nor the

MTMC/SDDC office contacted the FMCSA to report its findings, nor were they required

to do so.

Many of the deficiencies noted in the MTMC/SDDC 2001 inspection were the

same violations listed in the postaccident compliance review of Arrow and included

violations in vehicle maintenance, driver qualifications, and driver records. Both the

FMCSA in 1994 and MTMC/SDDC in previous inspections had identified these same

deficiencies on the part of Arrow. According to the FMCSA, one mechanism that can

trigger a compliance review is a complaint against a company. Had the MTMC/SDDC

information been shared with the FMCSA, it may have caused the FMCSA to conduct a

compliance review of Arrow before the accident. Additionally, in response to the

FMCSA’s postaccident compliance review, Arrow made changes, such as replacing

management and supervisory personnel, in an attempt to correct the FMCSR violations.

Therefore, the Safety Board concludes that although the FMCSA had not prioritized

Arrow for a compliance review from 1994 until the accident, the agency might have done

so if the MTMC had alerted the FMCSA to Arrow’s unsafe, repetitive practices

discovered during its inspection. The Safety Board believes that the MTMC/SDDC should

provide motor carrier information, including timely results of passenger carrier inspection

processes and ratings, to the FMCSA. Such an exchange would provide the FMCSA with

an additional opportunity to identify potentially unsafe motor carriers and schedule
Analysis 41 Highway Accident Report

compliance reviews. In addition, the Safety Board believes the FMCSA should utilize

motor carrier safety information, including results of compliance audit reports provided by

the MTMC/SDDC, to determine whether further review of a motor carrier is warranted. 

SafeStat

The FMCSA utilizes SafeStat to identify and prioritize carriers for FMCSA safety

improvement programs, such as roadside inspections and compliance reviews. The

SafeStat selection system is based on a carrier’s history of previous roadside inspections,

accidents, enforcement actions, and safety. The carrier’s SEA value approximates the

carrier’s percentile rank relative to all other carriers with sufficient data to be assessed

within the same SEA. 

The IG’s audit report presented to the FMCSA on February 13, 2004, made several

conclusions regarding the SafeStat program. The IG found that material weaknesses

existed in the data reported by the States and motor carriers and in the FMCSA’s processes

for correcting and disclosing data problems. The IG also determined that while SafeStat is

sufficient for internal use, its continued public dissemination and external use require

prompt corrective action. Both the IG’s office and the FMCSA, in its response to the audit,

agreed that existing data quality problems are likely to make a high-risk carrier appear to

be a safe operator. The IG’s report concluded:

[W]hen motor carriers and the states provide insufficient data it creates an

unknown degree of bias in SafeStat’s rankings of motor carriers and limits

SafeStat’s effectiveness as a tool for identifying high-risk carriers. As a result,

FMCSA cannot be sure it is focusing its resources for compliance reviews on

carriers with highest-risk....Additionally, missing, incomplete, or untimely safety

event data may cause public Internet users, who rely on specific rankings, to make

incorrect decisions.

The SafeStat system ranks all motor carriers in relation to each other. But ranking

passenger motor carriers in relation to nonpassenger carriers does not effectively draw

attention to passenger carriers that should be considered high-risk. As of February 20,

2004, over 678,000 recorded motor carriers with census data in SafeStat were actively

operating in interstate commerce. Of those, only 30,000 were passenger carriers.

Therefore, not only are passenger carriers underrepresented in the larger motor carrier

population, they are also underrepresented in SafeStat rankings. As a result, a passenger

carrier that ranks poorly compared with other passenger carriers, may not rank poorly

when compared to the larger population of motor carriers.

Because motorcoaches carry a large number of passengers who rely on the safety

assessment of a given carrier in making transportation decisions, it is critical that passenger

carriers be evaluated separately from the truck population. If passenger carriers were to be

rated and evaluated only in relation to other passenger carriers, the resulting safety

information would be more valid and would accurately highlight and prioritize unsafe

carriers for the public using the Internet database, as well as for the FMCSA in compliance

reviews or roadside inspections. Arrow had received a “pass” inspection recommendation,
Analysis 42 Highway Accident Report

even though not enough information on safety management was available for a rating;

however, had the rating for Arrow more accurately reflected its actual safety management

practices and adherence to the FMCSRs, the carrier may have been prioritized for an

updated compliance review between 1994 and the accident date. For example, data in

SafeStat included the Satisfactory rating Arrow had received during its 1994 compliance

review despite a high frequency of repeated noncompliance with Federal safety regulations.

The FMCSA recognized and discussed these issues with Arrow in all its compliance

reviews, yet the FMCSA neglected to conduct periodic compliance reviews until after the

Victor accident because Arrow was not rated a high-risk priority carrier in SafeStat.

Another accident investigated by the Safety Board also uncovered discrepancies in

the SafeStat system. In June 2002 in Loraine, Texas,79 a new entrant commercial motor

carrier, which had been operating for 22 months without a compliance review, collided

with a Greyhound motorcoach; three passengers were fatally injured and the driver and

five passengers were seriously injured. The FMCSA practice of conducting compliance

reviews based on the carrier’s SafeStat score was one reason the carrier had not received a

compliance review in 22 months. Yet many new entrant carriers, because they have not

been reviewed, have no score in the Safety Management area and have no accident history.

The Loraine accident carrier had high scores in the Vehicle and the Driver Safety

evaluation areas, indicating many violations in these two important areas. But, because

SafeStat uses a composite score, the carrier did not warrant a compliance review. As a

result of the Loraine investigation, the Safety Board concluded that the current SafeStat

system does not accurately reflect a new motor carrier’s safety posture because the

composite score is based on areas in which a new motor carrier may not be rated;

therefore, SafeStat is unlikely to provide FMCSA inspectors with enough data to

determine whether a safety audit should be performed sooner rather than later. 

This same situation existed in Arrow’s case, that is, the Safety Management area

did not have enough information for a rating. Therefore, the composite score for Arrow

indicated that the carrier did not warrant an inspection, and, as a result, a compliance

review was not performed between 1994 and the accident in 2002. Even though the Driver

and Vehicle areas included numerous violations in previous compliance reviews, this

information was not reflected in the SafeStat category in which Arrow was placed. As a

result of the Victor accident investigation, the Safety Board concludes that due to its

composite ranking methodology, the current SafeStat program does not accurately reflect

the safety fitness of motorcoach operators. The Safety Board believes that the FMCSA

should revise the SafeStat system to compare passenger carriers to other passenger carriers

to ensure accurate safety ratings. 

Compliance Reviews and Safety Rating Effectiveness

The purpose of the FMCSA compliance review is to make sure that a motor carrier

has adequate safety management controls in place to ensure compliance with applicable

79 National Transportation Safety Board, Collision of a Greyhound Lines, Inc., Motorcoach and Delcar

Trucking Truck Tractor-Semitrailer, Loraine, Texas, June 9, 2002, Highway Accident Report NTSB/HAR03/01 (Washington, DC: NTSB, 2003).
Analysis 43 Highway Accident Report

Federal safety requirements. The compliance review utilizes a computer tabulation

program to identify adherence with the FMCSRs in each rating factor based only on Acute

or Critical regulations, while the noncritical and nonacute violations are not factored into

the safety rating process. The Volpe National Transportation Systems Center reported that

for the year 2000, the FMCSA performed 12,624 compliance reviews; of these reviews,

3.2 percent resulted in no violations, 16.1 percent resulted in Acute violations, 54.3

percent resulted in Critical violations, and 95.8 percent resulted in other, noncritical or

nonacute violations. However, the noncritical or nonacute violations, regardless of the

number or presence in previous reviews, were not considered in the safety rating process.

After the Victor accident, Arrow was found to be in noncompliance with 12

specific regulations regarding the required alcohol and drug testing and had a completely

ineffective random testing program. Arrow failed to maintain the required records on the

effectiveness of the tests performed, resulting in 100 percent noncompliance. Arrow did

not complete driving record checks, which are undertaken to determine whether a driver is

properly qualified and has had a background check. Arrow required or permitted drivers to

drive for more than 10 hours, which violated the hours-of-service regulations. Arrow

failed to require drivers to sign driver vehicle inspection reports when defects or

deficiencies were noted. For 24 of 39 repair orders checked, Arrow did not have the

required certification to verify that the repairs were made, even though these buses

continued to transport passengers. The compliance review found violations that Arrow

failed to inspect and maintain vehicles to ensure safe and proper operating conditions as

well as failed to inspect safety items such as pushout emergency windows, emergency

doors, and emergency marking lights every 90 days. This lack of operational oversight

was also present during many FMCSA and MTMC/SDDC compliance reviews before the

accident, even as recently as the December 2001 MTMC/SDDC inspection.

The Victor accident is one of many in which the Safety Board has identified the

inadequacy of motor carrier inspections, including compliance reviews, as cause for

concern. For example, in 1995, the Safety Board investigated an accident in Indianapolis,

Indiana,80 in which the motorcoach overturned when it entered an exit ramp, and as a result,

2 passengers sustained fatal injuries and 13 received serious injuries. Postaccident inspection

of the vehicle revealed out-of-adjustment brakes, which probably contributed to the accident.

The Office of Motor Carriers (now the FMCSA) conducted a postaccident compliance review

of the operator, Hammond Yellow Coach Lines, Inc., (Hammond) that resulted in an

Unsatisfactory rating (10 out of 10 vehicles reviewed were placed out of service).

Hammond had significant safety problems before the accident and yet was still

permitted to operate. Between 1987 and 1995, the Office of Motor Carriers had inspected

Hammond nine times. In 1993, the agency gave Hammond an Unsatisfactory rating, citing

the carrier’s accident rate and hours-of-service violations; 3 months later, the agency

upgraded that rating to Satisfactory. In 1994, the agency used Indiana State Police terminal

inspection results to determine the rating for its compliance reviews. Because of the high

number of vehicles (63 percent) meeting out-of-service criteria, Hammond received a

80 National Transportation Safety Board, Selective Motorcoach Issues, Special Investigation Report

NTSB/SIR-99/01 (Washington, DC: NTSB, 1999).
Analysis 44 Highway Accident Report

Conditional rating for the Vehicle Factor component. But the agency rated all other factors

Satisfactory, resulting in an overall rating of Satisfactory, and Hammond continued to

operate with unsafe vehicles. Following the Indianapolis accident, the Safety Board

recommended that the FHWA: 

H-99-6

Change the safety fitness rating methodology so that adverse vehicle or

driver performance-based data alone are sufficient to result in an overall

unsatisfactory rating for the carrier.

On December 14, 1999, the Office of Motor Carriers responded that it expected to

issue a notice of proposed rulemaking calling for a more performance-based means of

determining carrier fitness to conduct commercial motor vehicle operations. The agency

stated that it would take into account the Safety Board’s recommendation, including any

comments received, in developing a new system. On March 17, 2000, based on the

expected notice of proposed rulemaking, the Safety Board classified Safety

Recommendation H-99-6 “Open–Acceptable Response.” The Board also added the

recommendation to its Most Wanted List of Transportation Safety Improvements to

increase the public’s awareness of and support for action to adopt safety steps that can

help prevent accidents and save lives. 

Had the earlier compliance reviews of Arrow resulted in Unsatisfactory ratings,

the carrier would have only had 45 days to correct the problems or cease operations.

Instead, it received Conditional and Satisfactory ratings and continued to operate for 8

years without another review of its safety operations, even though the DOT notified a U.S.

Senator that the DOT “would closely monitor Arrow Line vehicle and driver safety

operations.”81 If the FMCSA received notification from the MTMC/SDDC when the latter

inspects a motorcoach operation and gives the carrier a poor rating, if a more accurate

SafeStat system for motorcoaches were in place, and if the compliance review rating

methodology were revised to give appropriate weight to the driver and vehicle safety

areas, the FMCSA would have accurate information regarding a carrier’s level of passenger

safety; under such conditions, Arrow would have received an Unsatisfactory rating.

In 2001, the Safety Board investigated an accident in Mountainburg, Arkansas,82 in

which a postaccident compliance review of the motor carrier, Stuart Trucking, resulted in

a Conditional rating. The motor carrier received the FMCSA compliance review following

an accident in which a Stuart Trucking truck collided with a school bus and killed three

children. The postaccident compliance review resulted in a Conditional rating for Factor

2-Driver, a Satisfactory rating for Factor 4-Vehicle, an Unsatisfactory rating for Factor 5-

Accident, and an overall Conditional rating.

81 From the DOT Office of Congressional Affairs’ correspondence of October 31, 1995.

82 National Transportation Safety Board, Collision Between Truck Tractor Semitrailer and School Bus

near Mountainburg, Arkansas, on May 31, 2001, Highway Accident Report NTSB/HAR-02/03

(Washington, DC: NTSB, 2002).
Analysis 45 Highway Accident Report

The Safety Board determined that even if the Vehicle rating had been changed to

Conditional as a result of the 2001 compliance review, Stuart Trucking’s overall rating

would have remained unchanged. Under current compliance review procedures, one

Unsatisfactory factor rating and two or fewer Conditional factor ratings result in an overall

Conditional rating. The 2001 rating for Stuart Trucking underscores the failure of

compliance reviews to identify unsafe carriers. This carrier had not been rated in more

than 11 years at the time of the accident. Despite having unsafe vehicles on the road and

numerous driver violations, Stuart Trucking received a Conditional rating. As a result of

the Mountainburg accident, the Safety Board reiterated Safety Recommendation H-99-6

to the FMCSA on September 4, 2002, urging the agency to change the safety fitness rating

methodology so that adverse vehicle and driver performance-based data alone are

sufficient to result in an overall Unsatisfactory rating. 

Like Stuart Trucking, Arrow received a Conditional rating as a result of a

postaccident compliance review. Although the FMCSA inspected 20 motorcoaches and

placed 8 buses out of service, for an out-of-service rate of 40 percent, and in spite of

Arrow’s numerous other violations, the carrier received the Conditional rating. During the

postaccident compliance review, the FMCSA stated that Arrow “revealed a noncompliance with the Federal Motor Carrier Safety Regulations in almost all applicable

parts to Arrow’s passenger transportation.” However, many violations were not rated as

Acute or Critical and therefore did not result in Conditional or Unsatisfactory factor

ratings, even in the driver-related areas. The compliance review resulted in Satisfactory

ratings for four of the five applicable factors and, thus, an overall Conditional rating, even

though Arrow had violated nearly all applicable regulations. The Safety Board concludes

that the current FMCSA compliance review process does not effectively identify unsafe

motorcoach operators and prevent them from operating. 

Following the Board’s September 2002 reiteration of Safety Recommendation

H-99-6, the FMCSA advised the Safety Board that it intended to issue a notice of

proposed rulemaking regarding the safety fitness rating methodology in late 2003. Thus

far, 5 years after the Safety Board first issued the recommendation, the FMCSA still has

not published a notice of proposed rulemaking. In June 2004, the FMCSA notified the

Board that it anticipates making a final determination concerning changes to the safety

fitness rating methodology in 2004. The FMCSA indicated that it was considering

whether to seek additional comments through a supplemental advanced notice of proposed

rulemaking or to proceed directly to a notice of proposed rulemaking. The FMCSA

anticipates completing the rulemaking process in 2005. Although the Safety Board is

disappointed that the FMCSA has not acted on Safety Recommendation H-99-6, the action

announced by the FMCSA is a positive, albeit overdue, effort to address this critical issue. 

Survival Aspects and Motorcoach Crashworthiness

In the Victor accident, during the overturn of the bus onto its right side, many

passengers were thrown toward the right into other passengers and into seats, windows,

and other interior components. Because the glazing failed on the right side during the
Analysis 46 Highway Accident Report

overturn, the risk of ejection increased. In the case of the five ejected passengers found

under the motorcoach, their contact with the windows that shattered during the vehicle’s

structural distortion and overturn caused them to be ejected, pinned beneath the stillmoving vehicle, and fatally injured. Another ejected passenger who was seriously, but not

fatally, injured and who had been seated in the front right side of the motorcoach told the

NYSP she was ejected through the front windshield.

The motorcoach’s interior compartment was not compromised by intrusion during

the accident sequence and therefore adequate survivable space for the occupants was

available. Based on the Safety Board’s simulations, given the available survivable space

within the passenger compartment postaccident, had the passengers remained in their

seating area, their exposure to injury-causing impacts and to ejection would have been

reduced and they probably would not have sustained such serious, or fatal, injuries. The

passenger’s injuries were a direct result of leaving the seating compartment, contacting

other passengers and the vehicle’s interior components, or being ejected during the accident

sequence. The Safety Board concludes that the lack of motorcoach occupant protection

systems to retain passengers in their seating compartment throughout the accident sequence

contributed to the ejections and to the passengers’ serious and fatal injuries. 

Occupant ejection is a major cause of death in automotive crashes, accounting for

over 10,000 deaths each year. In 2001, passenger vehicle rollovers resulted in 10,642

fatalities, and of these, 3,766 fatalities involved complete or partial ejection. The

mitigation of these ejections is one of the most important objectives in rollover safety. 83

The fact that restraint systems prevent ejection during overturn accidents is well known.

Motorcoaches are equipped with large panoramic windows that often fracture during

rollovers and provide large open areas for ejection. As in the case of the Victor accident,

fatalities in motorcoach collisions are often due to occupant movement outside of the

seating compartment and ejections. Currently, no Federal regulation or standard exists that

requires large motorcoaches, sold or operated in the United States, to be equipped with

active or passive passenger protection. In Europe, regulations are in place that apply to the

strength of the motorcoach superstructure and the strength of seats and their anchorages.

These regulations are not compulsory, but manufacturers take them into account in

developing, approving, and testing new motorcoaches.84 The fitting of seat belts in Europe

varies from country to country; however, the European Union Commission is attempting

to make compliance with the seat belt regulation for new vehicles mandatory throughout

the continent. In Australia, as a result of the number of severe motorcoach collisions and

significant public pressure, regulations were introduced to address motorcoach rollover

strength, seat and seat anchorage strength, and lap/torso restraints for motorcoaches.85

83 Donald T. Willke, Stephen Summers, J. Stephen Duffy, Allison E. Louden, and Jeffrey C. Elias,

“Status of NHTSA’s Ejection Mitigation Research Program.” ESV Conference Paper #342, May 19-22,

2003, Nagoya, Japan.

84 RONA Kinetics and Associates, LTD.

85 RONA Kinetics and Associates, LTD.
Analysis 47 Highway Accident Report

In the Safety Board’s 1999 bus crashworthiness study,86 the Board found that one

of the primary causes of preventable injury in motorcoach accidents was occupant motion

out of the seat during a collision. Two of the recommendations issued in that report also

apply to the Victor accident. The Safety Board recommended that NHTSA:

H-99-47

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-99-48

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.

On October 27, 2000, NHTSA responded that it had initiated a research plan in

conjunction with motorcoach manufacturers to support the motorcoach crashworthiness

recommendations. The Safety Board reiterated Safety Recommendations H-99-47 and -48

to NHTSA on August 28, 2001, as a result of the Board’s investigation of a motorcoach

accident in New Orleans, Louisiana,87 in which 22 passengers died, 10 of whom had been

ejected from the bus. In its report of the New Orleans accident, the Safety Board noted that

it had identified occupant protection issues similar to those discussed in the Bus

Crashworthiness Issues report. On March 6, 2002, NHTSA advised the Safety Board that

it had assisted in the formation of the Bus Manufacturers Council, which will work to

create industry-wide standards to enhance motorcoach safety. NHTSA also sponsored a

motorcoach public safety meeting on April 30, 2002. Therefore, on June 28, 2002, the

Safety Board classified Safety Recommendations H-99-47 and -48 “Open–Acceptable

Action,” pending development of industry-wide standards for occupant protection.

Recent motorcoach accidents that have occurred since the Safety Board’s 1999 bus

crashworthiness study continue to underscore the need for action from NHTSA in

response to the Board’s recommendations on motorcoach occupant protection. In the

Victor accident, the majority of the passengers sustained minor injuries, while those fatal

injuries sustained were a direct result of being ejected from the motorcoach or the seating

compartment. In another accident investigated by the Board that occurred in Loraine,

Texas,88 a motorcoach operated by a driver and occupied by 37 passengers rear-ended a

slow-moving tractor semitrailer. The Safety Board determined that the seriously injured

passengers seated further to the rear of the area of impact were most likely thrown out of

86 NTSB/SIR-99/04.

87 National Transportation Safety Board, Motorcoach Run-off-the-Road, New Orleans, Louisiana, May

9, 1999, Highway Accident Report NTSB/HAR-03/01 (Washington, DC: NTSB, 2001).

88 NTSB/HAR-03/01.
Analysis 48 Highway Accident Report

their seating compartment during the collision events, thus sustaining their injuries. The

Safety Board concluded from the Loraine accident investigation that the lack of a restraint

system for the passengers contributed to the injuries of those seated outside the area of

impact.

The Safety Board is currently investigating other motorcoach accidents in Hewitt,

Texas, and Tallulah, Louisiana. In both accidents, passengers were also injured and killed

after being thrown from their seating compartments into the area of impact. Currently, the

United Kingdom and Australia require restraints, and Europe and Australia are actively

researching, developing, and testing measures to improve occupant protection systems

that can help prevent ejections, mitigate injuries, and reduce fatalities (for example, the

development and testing of seat anchorage systems, the universal coach safety seat with

three-point restraints, and the modeling and testing of coach structures for rollover

strength). The tragic consequences of the Victor accident, as well as the Hewitt and

Tallulah accidents, add urgency to Safety Recommendations H-99-47 and -48 to develop

performance standards for motorcoach occupant protection systems that retain occupants

within the seating compartment throughout accident scenarios. To date, NHTSA has done

little to implement these recommendations; therefore, the Safety Board reiterates Safety

Recommendations H-99-47 and -48.
49 Highway Accident Report

Conclusions

Findings

1. The weather, the design and condition of the roadway, the mechanical condition of the

motorcoach, and the driver’s diabetes did not contribute to the accident; the test

results showed no evidence of drug or alcohol use by the driver, and the emergency

response was adequate.

2. The bus driver had less than 4 hours of interrupted sleep in a 51-hour period as a

result of deliberately spending his off-duty hours in a casino; he was, therefore,

severely fatigued at the time of the accident.

3. The accident bus left the roadway as a result of the driver falling asleep.

4. Even if passengers had called Driver’s Alert to report the driver, a system was not in

place to allow Arrow Line, Inc., to take immediate action. 

5. Had Arrow Line, Inc., provided a method for passengers to contact the company to

report the driver’s severely fatigued condition, the company could have prevented the

driver from beginning or continuing the accident trip. 

6. The driver of the second Arrow Line, Inc., motorcoach did nothing to prevent the

severely fatigued accident driver from transporting passengers in his impaired

condition. 

7. At the time of the accident, Arrow Line, Inc., had a documented history, as evidenced

in Federal Motor Carrier Safety Administration compliance reviews, of failing to

adequately oversee operational safety issues and failing to recognize and correct

inherent safety problems.

8. Although the Federal Motor Carrier Safety Administration had not prioritized Arrow

Line, Inc., for a compliance review from 1994 until the accident, the agency might

have done so if the Military Traffic Management Command had alerted the Federal

Motor Carrier Safety Administration to the Arrow Line, Inc.’s unsafe, repetitive

practices discovered during its inspection.

9. The current Federal Motor Carrier Safety Administration compliance review process

does not effectively identify unsafe motorcoach operators and prevent them from

operating. 

10. Due to its composite ranking methodology, the current SafeStat program does not

accurately reflect the safety fitness of motorcoach operators. 
Conclusions 50 Highway Accident Report

11. The lack of motorcoach occupant protection systems to retain passengers in their

seating compartments throughout the accident sequence contributed to the ejections

and to the passengers’ serious and fatal injuries.

Probable Cause

The National Transportation Safety Board determines that the probable cause of

the accident was that the bus driver fell asleep while operating the motorcoach due to his

deliberate failure to obtain adequate rest during his off-duty hours. Contributing to the

cause of the accident was the second Arrow Line, Inc., motorcoach driver, who did

nothing to prevent the severely fatigued driver from operating the accident motorcoach,

and the failure of Arrow Line, Inc., and its holding company, Coach USA, to provide

adequate oversight of their drivers. Contributing to the severity of the accident was the

lack of occupant restraints for the motorcoach passengers.
51 Highway Accident Report

Recommendations

New Recommendations

To the Federal Motor Carrier Safety Administration:

Require the posting of an emergency telephone number on the interior of motorcoaches for passengers to call in the event of an emergency with the driver. (H-04-18)

Revise the Safety Status Measurement System to compare passenger carriers to

other passenger carriers to ensure accurate safety ratings. (H-04-19)

Utilize motor carrier safety information, including results of compliance audit

reports provided by the U.S. Department of Defense Surface Deployment and

Distribution Command, to determine whether further review of a motor carrier is

warranted. (H-04-20)

To the U.S. Department of Defense Surface Deployment and Distribution Command:

Provide motor carrier information, including timely results of passenger carrier

inspection processes and ratings, to the Federal Motor Carrier Safety

Administration. (H-04-21)

To Coach USA and its subsidiaries:

Evaluate all calls reporting dangerous driver behaviors immediately upon receiving

them and establish a method to reach the driver so that Coach USA can evaluate the

driver’s fitness for duty and take appropriate countermeasures, if necessary. (H-04-22)

Reiterated Recommendations

The National Transportation Safety Board also 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)
Recommendations 52 Highway Accident Report

BY THE NATIONAL TRANSPORTATION SAFETY BOARD

ELLEN ENGLEMAN CONNERS JOHN J. GOGLIA

Chairman Member

MARK V. ROSENKER CAROL J. CARMODY

Vice Chairman Member

RICHARD F. HEALING

Member

Adopted: June 22, 2004
53 Highway Accident Report

Appendix A

Investigation and Public Hearing

The National Transportation Safety Board was notified of the Victor, New York,

accident on June 23, 2002. An investigative team was dispatched on July 7, 2002, with

members from the Washington, D.C.; Denver, Colorado; Gardena, California; and

Parsippany, New Jersey, offices. Groups were established to investigate human

performance aspects; motor carrier operations; and highway, vehicle, and survival factors.

Participating in the investigation were representatives of the Federal Motor Carrier

Safety Administration, the New York State Police, the New York State Thruway

Authority, and Motor Coach Industries, Inc.

No public hearing was held; no depositions were taken.
54 Highway Accident Report

Appendix B

Arrow Compliance Review and Safety Rating History

Compliance review date Rating date Rating

July 18, 1989 September 20, 1989 Unsatisfactory

December 21, 1989 January 26, 1990 Conditional

August 20, 1990 August 30, 1990 Conditional

October 3, 1990 October 9, 1990 Satisfactory

March 18, 1992 May 28, 1992 Satisfactory

June 24, 1994 July 18, 1994 Conditional

November 21, 1994 December 8, 1994 Satisfactory

August 8, 2002 (postaccident) October 8, 2002 Conditional
55 Highway Accident Report

Appendix C

Safety Evaluation Area Criteria

Within SafeStat, motor carriers are evaluated in four Safety Evaluation Areas

(SEAs): Accident, Driver, Vehicle, and Safety Management. Based on the value assigned

to a carrier, carriers are then ranked against other carriers within their peer group and are

assigned a percentile in the range of 0-100 (100 being the worst). Then all four SEA

values are combined and an overall SafeStat score is calculated. Only carriers that have

deficient SEA values of 75 and higher in two or more SEAs receive a SafeStat score that is

equal to the sum of the deficient SEA values for the Vehicle and Safety Management

SEAs, plus two times the deficient Accident SEA value, plus 1.5 times the deficient

Driver SEA value. The single SEA category SafeStat score is based on carriers deficient in

one SEA. 

Category SafeStat score range Includes SEA values of 75 or higher

A >350 to <550 All 4 SEAs

3 SEAs that result in score of 350 or more

B >225 to >350 3 SEAs that result in score of less than 350

2 SEAs that result in score of 225 or more

C >150 to <225 2 SEAs that result in score of less than 225

2 SEAs that result in score of 150 or more

Single SEA category Specific SEA SEA value

D Accident 75 to 100

E Driver 75 to 100

F Vehicle 75 to 100

G Safety Management 75 to 100

H All Less than 75
56 Highway Accident Report

Appendix D

ISS-2 Recommendation and Inspection Values

The Federal Motor Carrier Safety Administration computer program Inspection

Selection System (ISS-2) was designed to assist field inspectors with selecting vehicles

for inspection by identifying the carriers and vehicles that have a history of unsafe

practices and poor safety performance. The ISS-2 criteria are based on data analysis from

the Motor Carrier Management Information System, SafeStat ratings, or PRISM.1

 If

SafeStat contains insufficient data, the ISS-2 values are based on carrier size and the

number of past inspections. The inspector’s ISS-2 inquiry results in one of three

responses: Pass, Optional, and Inspect. Carriers are rated on a 100-point system. 

The ISS-2 also displays a section on the carrier’s violation details that compares

the carrier’s violation history to the national violation warning threshold2 in specific

categories. Carriers that have a violation history greater than the warning threshold are

highlighted, alerting the inspector to concentrate on or closely attend to those items during

an inspection process.

1 A Federal and State program that links motor carrier safety fitness to State commercial vehicle

registrations. For more information, access <www.fmcsa.dot.gov/factfigs/Prism.htm>.

2 A Federal Motor Carrier Safety Administration algorithm using national inspection histories and

carrier census information.

Recommendation ISS-2 inspection value

Inspect (inspection warranted) 75-100

Optional (may be worth a look) 50-74

Pass (no inspection required) 1-49
Appendix E 57 Highway Accident Report

Appendix E

FMCSA Compliance Reviews and Roadside Inspections

On June 7, 2004, the Federal Motor Carrier Safety Administration reported

674,101 active interstate carriers, of which 10,183, or 1.5 percent, were active interstate

passenger carriers with at least one motorcoach. The FMCSA further reported the

following statistics:

Table 6. Number of Federal compliance reviews conducted on active interstate

passenger motorcoach carriers* and roadside inspections conducted in fiscal years 2003,

2002, and 2001.**

*As of June 7, 2004, according to the Federal Motor Carrier Safety Administration.

**As of March 31, 2004, according to the Federal Motor Carrier Safety Administration’s Motor Carrier Safety Progress Report.

Program output Fiscal year 2003 Fiscal year 2002 Fiscal year 2001

Compliance reviews on active 

interstate carriers

11,270 8,826 10,840

Compliance reviews on active 

interstate passenger carriers with at 

least one motorcoach

261 250 441

Percentage of compliance reviews on 

active interstate passenger carriers

2.32% 2.83% 4.07%

Roadside inspections, trucks 2,993,176 2,904,348 2,627,605

Roadside inspections, buses 42,218 38,932 35,786

Table E-1.
58 Highway Accident Report

Appendix F

October 2002 FMCSA Compliance Review of Arrow Line, Inc.

The following is a verbatim excerpt from the October 2002 compliance review of

Arrow Line, Inc.

19 out of 191 random tests from January 1 through May 30, 2002, were performed on drivers who were 

not selected by scientifically valid method, nor were they listed as alternate on random controlled alcohol 

selection lists. Results were in 9.9 percent violation rate.

162 safety sensitive employees out of 334 selected for random controlled substance and/or alcohol 

testing, were either not tested or test results were unavailable to confirm tests were in fact performed. This 

was 49 percent violation rate.

29 out of 146 driver vehicle inspection reports were unavailable (or not prepared and submitted) for 

interstate trips made for 8 out of 11 vehicles checked. This resulted in 25 percent violation rate.

Using driver before motor carrier has received negative preemployment controlled substance test result.

Failing to prepare and maintain on file record stating reasons alcohol and controlled substances 

postaccident tests were not properly administered.

Failing to ensure that each driver selected for random alcohol and controlled substances testing has equal 

chance of being selected each time selections are made.

Failing to maintain list or certificate relating to violations of motor vehicle laws and ordinances required by 

391.27.

Failing to maintain inquiries into driver’s employment record in driver’s qualification file.

Failing to ensure that drivers are tested within selection period.

Failing to ensure persons designated to determine that drivers undergo reasonable suspicion testing 

receive 60 minutes training for alcohol and/or 60 minutes of training for controlled substances.

Failing to maintain medical examiner’s certificate in driver’s qualification file.

Requiring or permitting driver to drive after having been on duty 15 hours.

Failing to require inspector to prepare periodic inspection reports as prescribed.

Failing to obtain from driver for first time or intermittently a signed statement giving total time on duty 

during preceding 7 days and time which last relieved from duty.

Failing to inspect push-out windows, emergency doors, and emergency marking lights in buses at least 

every 90 days.

Failing to certify that reports were made or not necessary.
Appendix F 59 Highway Accident Report

65 out of 232 Arrow Line, Inc., employees who performed safety sensitive functions were not enrolled in 

Arrow Line, Inc., random controlled substance and alcohol selection pool, based on current Arrow Line, 

Inc., safety sensitive employees list and list of drivers currently enrolled in random controlled substance 

and alcohol selection pool, as of July 1, 2002. This resulted in 28 percent violation rate.

34 out of 604 records of duty status checked were noted as False Record of Duty Status for 6 out of 18 

drivers checked; 6 percent violation rate. Falsification of records of duty status was discovered for drivers 

designated as Part Time, and numerous part-time drivers had outside employment in addition to Arrow 

Line, Inc., and failed to report additional work hours on records of duty status submitted.

Using driver to perform safety sensitive functions after failing to obtain information required by 40.25(b), 

from previous employers within 30 days without obtaining or making and documenting good faith effort to 

obtain information.

Failing to conduct postaccident alcohol and controlled substances testing for each surviving driver.

Failing to use scientifically valid method to select drivers for random testing.

Failing to maintain driver’s employment application in driver’s qualification file.

Failing to maintain a note relating to the annual review of driver’s driving records as required by 391.25(c) 

(2).

Failing to make an inquiry into the driving record of each driver to the appropriate State agencies in which 

the driver held a commercial motor vehicle operators license at least once every 12 months.

Failing to investigate driver’s background.

Required, permitted, or authorized an employee with Commercial Driver’s License which is suspended, 

revoked, or cancelled by State or who is disqualified to operate commercial motor vehicle.

Requiring or permitting driver to drive more than 10 hours.

False reports of records of duty status. False reports of records of duty status (inaccurate).

Failing to require driver to prepare record of duty status in form and manner prescribed.

Failing to inspect and maintain vehicle to ensure safe and proper operating condition.

Failing to require driver to prepare driver vehicle inspection report.

Failing to require driver to sign vehicle inspection report when defects or deficiencies were noted.
60 Highway Accident Report

Appendix G

DOT Office of Inspector General Report

The following information is a verbatim excerpt from the recommendations in the

U.S. Department of Transportation Office of Inspector General’s (OIG’s) Report (MH2004-034) and from the U.S. Department of Transportation Federal Motor Carrier Safety

Administration’s (FMCSA’s), January 14, 2004, response to those recommendations.

OIG Recommendation # A1.

Initiate an effectiveness study of the current model that tests the model’s key

parameters, assesses possible model adjustments to account for missing data, and

evaluates whether the use of vehicle miles traveled or adjustments for team

drivers would improve SafeStat calculations. The result of the study should be

subjected to independent review by a party outside of Volpe.

FMCSA Response to A1.

FMCSA has an independent analysis contractor on board to revalidate the

SafeStat model. The study should begin early in 2004.

OIG Recommendation # A2.

Establish processes for soliciting public comment on proposed changes in

SafeStat calculations, to include those changes if any, resulting from the revised

effectiveness study.

FMCSA Response to A2.

FMCSA has an effective public comment process. The FMCSA’s Analysis &

Information online site that displays SafeStat data to the public has a feedback

mechanism, whereby the industry and public can offer suggestions on

improvements. In fact, the majority of SafeStat changes have originated from

industry and other stakeholder feedback. FMCSA will explore the feasibility of

using the existing feedback mechanism on A&I to solicit public comment on

proposed changes.

OIG Recommendation # B1.a.

Take immediate action to mitigate the impact of inaccurate or incomplete data on

public users of SafeStat by making available to all states an improved system for

facilitating the correction of data inaccuracies and the tracking of corrective

actions within 3 months following the issuance of this report.

FMCSA Response to B.1.a.

In late January 2004, FMCSA will implement the DataQs system, an electronic

means for filing concerns about Federal and State data released to the public by

FMCSA. Through this system, data concerns are automatically forwarded to the
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appropriate office for resolution. This system will simplify the existing process

and provide a mechanism for FMCSA, the States, and the public to track data

challenges. In addition, monthly updates of SafeStat scores should be recognized

as a data quality improvement. Now, when a carrier updates its census data and

gets an inaccuracy corrected, its SafeStat score will show an improvement in 30

days or less, instead of up to 6 months later.

OIG Recommendation # B.1.b.

Take immediate action to mitigate the impact of inaccurate or incomplete data on

public users of SafeStat by disclosing data problems, including variations in State

reporting, to public users of SafeStat.

FMCSA Response to B.1.b.

FMCSA will add clear and comprehensive guidance for web users as to the limitations

of the data by the end of January 2004. We will further enhance this guidance by

adding information on each State’s timeliness, accuracy, and completeness.

OIG Recommendation # B.2.a.

As expeditiously as possible, establish an overall data quality improvement

program that addresses longstanding issues associated with motor carrier census

data by imposing fines on carriers that fail to provide updated carrier census

information despite repeated opportunities to do so.

FMCSA Response to B.2.a.

Beginning January 2004, all reminder notices sent to motor carriers about filing

their biennial update will contain the following statement: Even if the information

has not changed or your company is no longer in business (or no longer operating

commercial vehicles in interstate commerce), we need you to file this update.

Please note that, under 49 CFR 390.19(e), failure to file a new and accurate Form

MCS-150 may result in the imposition of a civil penalty of $550 for each offense.

Each day the violation continues constitutes a separate offense, and the total

penalty for all offenses related to a single violation may reach $5,500. In January

2003, to help improve the response rate of the biennial update, FMCSA provided

an easy way for carriers to update their census data online. Currently, 40 percent

of carriers are providing updates in this manner. We also developed a plan for

addressing the missing respondents and are weighing implementation options. In

addition, FMCSA’s New Entrant program meets with each new motor carrier

within the first 18 months of operations and conducts a safety audit. In this audit,

census data is verified and updated. If the new entrant fails to pass the safety audit,

the USDOT number is revoked.

OIG Recommendation # B.2.b.

As expeditiously as possible, establish an overall data quality improvement

program that sets minimum standards for the quality of SafeStat data consistent

with the Department’s data quality guidelines. At a minimum, the standards

should address completeness, accuracy, and timeliness of data.
Appendix G 62 Highway Accident Report

FMCSA Response to B.2.b.

FMCSA is undertaking a continuous data quality process, including developing a

comprehensive data quality plan in FY 2004. Some of the planned components of

this process include: (1) awarding a contract to conduct a sample certification of

source documents (inspection and crashes) against what is uploaded; (2)

coordinating with OIG to identify additional edit checks, (3) conducting training

sessions at FMCSA’s IT workshop that specifically address data quality issues, (4)

assigning a person in FMCSA to review the monthly timeliness, non-match, and

traffic enforcement reports by State to identify problems and work with States to

resolve them, and (5) review recently completed analysis on improving the

biennial update response rate. FMCSA has set data quality goals for timeliness,

completeness, and accuracy of crash data. 

OIG Recommendation # B.2.d.

As expeditiously as possible, establish an overall data quality improvement

program that enhances the depth, frequency, and type of FMCSA State data

quality reviews and monitoring, and ensures State plans address data quality.

FMCSA Response to B.2.d.

FMCSA responded that part of their continuous data quality process will involve

assigning a person in FMCSA to review the monthly timeliness, non-match, and

traffic enforcement reports by State to identify problems and work as part of the

Commercial Vehicle Analysis Reporting System (CVARS) program. 

OIG Recommendation # B.2.c.

As expeditiously as possible, establish an overall data quality improvement

program that accomplishes actions planned, in conjunction with the National

Highway Traffic Safety Administration, for improving the completeness and

timeliness of state-reported crashes.

FMCSA Response to B.2.c.

In early Summer 2003, FMCSA provided grants to 22 States under the

Commercial Vehicle Analysis Reports System (CVARS) program to improve their

crash data reporting. We recently found that 11 of these States had shown a

marked increase in the completeness of crash data reporting. We continue to

include more States in CVARS, and have established goals for accuracy,

timeliness, and completeness. Through training and data system improvements,

we expect the States to make significant strides in the quality of crash data

reporting.with the States to resolve them.

OIG Recommendation # B.2.e.

As expeditiously as possible, establish an overall data quality improvement

program that modifies FMCSA guidance and funding decisions so that MCSAP

incentive grant awards are based, in part, on each State’s implementation of

guidelines established to provide accurate, complete, and timely safety event data.
Appendix G 63 Highway Accident Report

FMCSA Response to B.2.e.

FMCSA responded that they could not agree with the specific approach of

penalizing States for data problems, because they believe that withholding funds

may lead to a reduced level of enforcement. In the alternative, FMCSA believed

that providing incentive funding to States will assist them in improving data

quality reporting processes. In fact, receiving high priority MCSAP grants will be

tied to participation in the DataQ system. This information we sent out in midJanuary to each MCSAP agency.

On May 11, 2004, the FMCSA provided the Safety Board with the following

updated status of its progress in response to the OIG audit report (MH-2004-034) of the

FMCSA SafeStat system.

FMCSA updated response to A1:

The Volpe Center conducted an updated effectiveness study of the current

SafeStat version 8.5 and recent motor carrier data (available as of March 2003).

The updated study (dated March 2004) again confirmed SafeStat’s effectiveness.

The FMCSA has contracted with Oak Ridge National Laboratories (ORNL) to

independently review and validate the findings of the updated report. ORNL held

an initial meeting with the Volpe Center authors on February 25, 2004. ORNL

submitted a draft statement of work outlining its strategy for conducting the

validation to the Analysis Division of Volpe, and ORNL proposes to complete its

draft validation report by June 30, 2004. The Analysis Division of Volpe will

review the draft validation report, share it with others within FMCSA for their

review and concurrence, and present the final report to the FMCSA Administrator

no later than September 30, 2004. The FMCSA states the study is on target for

October 2004.

FMCSA updated response to A2:

FMCSA’s Analysis & Information online site that displays SafeStat data to the

public has a feedback mechanism available on every Web page whereby the

industry and public can provide comments and offer suggestions for

improvement. In fact, the majority of SafeStat changes have originated from

industry and other stakeholder feedback. FMCSA will modify the existing

feedback mechanism on A&I to solicit public comment on proposed changes. The

updated feedback mechanism was operational on April 30, 2004.

FMCSA updated response to B1.a:

On February 27, 2004, we implemented the new electronic system (DataQs) for

filing concerns about Federal and State data released to the public by FMCSA.

FMCSA updated response to B1.b:

FMCSA implemented a “SafeStat Disclaimer” Web page on SafeStat Online in

January 2004 that cautions users on the appropriate use of SafeStat data. All

public users of SafeStat Online must acknowledge this cautionary message before

proceeding into SafeStat Online. In addition, FMCSA developed a report that

rates the quality of individual State crash and inspection data reporting on the

basis of data completeness, timeliness and accuracy. The report was approved by
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FMCSA top management on March 23, 2004, and is being sent to the States for

review, comment and concurrence. Within 60 days of approval of the final product

by FMCSA management, the report will be added to the A&I Online Web site. On

target for May of 2004.

FMCSA updated response to B2.a:

As noted in the OIG report (MH-2004-034), on January 1, 2004, FMCSA began

incorporating stronger language in the biennial update reminder letter to ensure

that motor carriers understand the penalties for not filing the updated information

on their operations. In spring 2004, FMCSA began working with motor carrier

organizations, such as the American Trucking Associations, to identify other

methods to ensure that motor carriers are aware of the update requirement.

Strategy developed to increase response to update requirements. Statistical

sampling of biennial update non-respondents has been identified by FMCSA and

reviewed by BTS and OST. Contacts will be made to determine why carriers did

not respond. On target for June of 2004. A requirement of PRISM is for the States

to deny International Registration Plan (IRP) license plate renewal when the

MCS-150 “date of last update” is greater than 12 months old at the time of

renewal. In other words, the States require that the carriers update if the MCS-150

will expire in the registration year. PRISM states that require MCS-150 update

with IRP renewal: Arizona, Colorado, Connecticut, Georgia, Indiana, Iowa,

Kentucky, Maine, Minnesota, North Carolina, Ohio, Pennsylvania, South Dakota,

Tennessee, and Washington.

FMCSA updated response to B2.b:

FMCSA will develop the initial version of a comprehensive data quality plan by

July of 2004. This plan will be an evolving document addressing new data

improvement methods as they are identified. The initial plan will provide for oneon-one contact with State document processors; verification of source documents;

identification of additional edit checks; conducting training sessions on data

quality issues; assigning staff to monitor reports on the quality of State data; and

addressing the analysis of the biennial update non-respondents. It will also set

quality goals for timeliness, completeness and accuracy as part of the Commercial

Vehicle Analysis Reporting System (CVARS) program. A comprehensive data

quality plan is on target for July of 2004.

FMCSA updated response to B2.c:

FMCSA’s Analysis Division has developed a draft project plan (dated February

24, 2004) that presents a multi-faceted, multi-year strategy for a nationwide crash

data improvement project. This project will culminate in significant

improvements to the collection and reporting of eligible large truck and bus crash

data by the States through SAFETYNET to the FMCSA. It contains a list of major

tasks and deliverables as well as associated activities within each task. The project

plan establishes the following goal: all States and the District of Columbia will

report complete, accurate and timely data on all data elements identified by

FMCSA for at least 95 percent of all eligible trucks and buses involved in all

eligible crashes by September 30, 2010. In summary, the long-term project goal is

nearly full reporting with improved timeliness, accuracy, and completeness.

FMCSA will seek input from NHTSA and other organizations regarding the draft

plan, and will look for partnering opportunities in implementing the plan.
Appendix G 65 Highway Accident Report

The project plan also includes helping the States improve their processes for

collection and use of commercial motor vehicles (CMV) involved crash

information (through FMCSA-sponsored training and education) so that there is a

lasting improvement in quality of data and analysis; helping States improve the

CMV-related portions of their Traffic Records Systems in order to support the

improved collection and reporting of crash information; facilitating and

encouraging a close working relationship between FMCSA division

administrators and stakeholders in the State’s motor carrier safety environment. In

the plan, States will be asked to (1) work with FMCSA to assess their crash data

reporting strengths and weaknesses and (2) develop proposals for assistance

(financial and non-financial) from FMCSA. FMCSA will then evaluate, approve

(if viable), and fund viable State proposals, using funding provided by the U.S.

Congress for crash data improvements. FMCSA will ensure that each proposal

includes metrics that allow FMCSA to periodically measure State crash data

accomplishments, and the agency will establish and implement a tracking system

to monitor State accomplishments quarterly and provide quarterly feedback to

States. The plan has been completed, NHTSA has submitted their comments, and

the OIG has reviewed it.

FMCSA updated response to B2.d:

FMCSA’s data quality coordinator has been assigned the responsibility for

monitoring the monthly State reports in timeliness, non-match and traffic

enforcement records and working with the appropriate States to resolve issues.

The reviews will begin in spring 2004. As noted in the response to

Recommendation B2.c, FMCSA will work with the States to ensure their plans

address data quality. This is on target for June 2004.

FMCSA updated response to B2.e:

As noted in the OIG report (MH-2004-034), FMCSA has taken an alternative

approach to meeting the objectives of this recommendation. In mid-January 2004,

FMCSA notified each Motor Carrier Safety Assistance Program (MCSAP)

agency that high priority grants will be contingent on its “participation in the

electronic tracking system for data challenges” known as DataQs. This has been

completed.