National 

Transportation

Safety Board

Washington, D.C.

National Transportation

Safety Board

Washington, D.C. 20594

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NTSB

Permit No. G-200

Highway Accident Report

15-Passenger Child Care Van 

Run-Off-Road Accident 

Memphis, Tennessee 

April 4, 2002

NTSB/HAR-04/02

PB2004-916202 National Transportation Safety Board

Notation 7623 490 LíEnfant Plaza, S.W.

Adopted April 7, 2004 Washington, D.C. 20594
National Transportation Safety Board. 2004. 15-Passenger Child Care Van Run-Off-Road Accident,

Memphis, Tennessee, April 4, 2002. Highway Accident Report NTSB/HAR-04/02. Washington, DC.

Abstract: On April 4, 2002, about 8:19 a.m., a 15-passenger Ford E-350 van, driven by a 27-year-old

driver and transporting six children to school, was southbound in the left lane of Interstate 240 in

Memphis, Tennessee. The van was owned and operated by Tippy Toes Learning Academy, a private child

care center. A witness driving behind the van stated that the vehicle was traveling about 65 mph when it

drifted from the left lane, across two other lanes, and off the right side of the roadway. She said that she did

not see any brake lights. The van then overrode the guardrail and continued to travel along the dirt and

grass embankment until the front of the van collided with the back of the guardrail and a light pole. The

rear of the van rotated counterclockwise and the front and right side of the van struck the bridge abutment

at the Person Avenue overpass before coming to rest. The driver was ejected through the windshield and

sustained fatal injuries. Four of the children sustained fatal injuries, and two were seriously injured.

The major safety issues discussed in this report are day care transportation oversight and highway barrier

design. As a result of this investigation, the Safety Board makes recommendations to child care

transportation oversight agencies in the 50 States and the District of Columbia, the State Departments of

Transportation, the National Association for the Education of Young Children, and the American

Association of State Highway and Transportation Officials. The Safety Board also reiterates a

recommendation to 39 States and the District of Columbia.

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

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

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

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

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

statistical reviews.

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

may be obtained from the Web site or by contacting:

National Transportation Safety Board

Public Inquiries Section, RE-51

490 LíEnfant Plaza, S.W.

Washington, D.C. 20594

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

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

purchase this publication, order report number PB2004-916202 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 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . vi

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

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

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

Injuries . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3

Medical and Pathological Information . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3

Survival Aspects . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4

Intrusion and Restraints . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4

Emergency Response . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5

Toxicological Tests . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5

 Driver Information . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5

Vehicle and Wreckage Information . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7

Highway Information . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9

Barrier System . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12

Accident History . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13

Physical Evidence . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14

Weather Information . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 18

Operational Information . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 18

Simulations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19

Vehicle Dynamics Simulation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19

Occupant Kinematics Simulation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 20

Bus Definitions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 23

School Bus . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 23

Multifunction School Activity Bus . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 23

School Bus Fatality Data . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 23

Child Care Transportation Laws and Guidance . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 24

Findings of Tennessee Committee on Child Care Agency Transportation Safety . . . 24

Child Care Transportation Laws in Tennessee . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 25

Child Care Transportation Laws in Other States . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 25

Head Start Transportation Law . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 28

National Highway Traffic Safety Administration Interpretation . . . . . . . . . . . . . . . . . 29

Booster Seats . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 29

Roadside Barrier Guidelines . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 29

Previous Recommendations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 30

Analysis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 31

Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 31

Accident Discussion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 32

Driverís Condition . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 33

Child Care Transportation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 36

Vehicle . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 36

Restraint Usage . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 37
Contents iv Highway Accident Report

Driver Fitness . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 38

Child Care Transportation Oversight . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 39

Barrier Design . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 42

Conclusions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 45

Findings . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 45

Probable Cause . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 46

Recommendations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 47

New Recommendations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 47

Previously Issued Recommendation Reiterated in This Report . . . . . . . . . . . . . . . . . . . . . . 48

Previously Issued Recommendation Classified in This Report . . . . . . . . . . . . . . . . . . . . . . 49

Appendixes

A: Investigation and Public Hearing . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 51

B: Previous Recommendations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 52

Restraint Usage . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 52

School Bus Occupant Protection Standards . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 53
v Highway Accident Report

Acronyms and Abbreviations

AASHTO American Association of State Highway and Transportation 

Officials

ABS antilock braking system

DHHS U.S. Department of Health and Human Services

ECS electronic crash sensor

EDSMAC4 Engineering Dynamics Corporation Simulation of Automobile 

Collisions

EDCRASH Engineering Dynamics Corporation Reconstruction of Accident 

Speeds on the Highway

FARS Fatality Analysis Reporting System

FHWA Federal Highway Administration

Ford Ford Motor Company

HbA1c hemoglobin A1c

HVE Human Vehicle Environment

I-240 Interstate 240

MADYMO MAthematical DYnamical MOdels

MFSAB multifunction school activity bus

μg/ml micrograms per milliliter

MPD Memphis Police Department

NAEYC National Association for the Education of Young Children

NHTSA National Highway Traffic Safety Administration

SIMON Simulation Model Non-linear

THC tetrahydrocannabinol

THC-COOH tetrahydrocannabinol carboxylic acid

TDHS Tennessee Department of Human Services

TDOT Tennessee Department of Transportation

Tippy Toes Tippy Toes Learning Academy
vi Highway Accident Report

Executive Summary

On April 4, 2002, about 8:19 a.m., a 15-passenger Ford E-350 van, driven by a 27-

year-old driver and transporting six children to school, was southbound in the left lane of

Interstate 240 in Memphis, Tennessee. The van was owned and operated by Tippy Toes

Learning Academy, a private child care center. A witness driving behind the van stated

that the vehicle was traveling about 65 mph when it drifted from the left lane, across two

other lanes, and off the right side of the roadway. She said that she did not see any brake

lights. The van then overrode the guardrail and continued to travel along the dirt and grass

embankment until the front of the van collided with the back of the guardrail and a light

pole. The rear of the van rotated counterclockwise and the front and right side of the van

struck the bridge abutment at the Person Avenue overpass before coming to rest. The

driver was ejected through the windshield and sustained fatal injuries. Four of the children

sustained fatal injuries, and two were seriously injured.

The Safety Board determines that the probable cause of this accident was the

absence of oversight by Tippy Toes Learning Academy and the driverís inability to

maintain control of his vehicle because he fell asleep, quite likely due to an undiagnosed

sleep disorder; the driverís marijuana use may also have had a role in the accident.

Contributing to the accident was the Tennessee Department of Human Servicesí lack of

oversight of child care transportation. Contributing to the severity of the injuries were the

use of a 15-passenger van to transport pupils, the nonuse of appropriate restraints, and the

design of the roadside barrier system.

The major safety issues discussed in this report are child care transportation

oversight and highway barrier design.

As a result of this investigation, the Safety Board makes recommendations to child

care transportation oversight agencies in the 50 States and the District of Columbia, the

State Departments of Transportation, the National Association for the Education of Young

Children, and the American Association of State Highway and Transportation Officials.

The Safety Board also reiterates a recommendation to 39 States and the District of

Columbia. 
1 Highway Accident Report

Factual Information

Accident Narrative

On April 4, 2002, about 8:19 a.m., a 15-passenger Ford E-350 van, driven by a 27-

year-old driver transporting six children to school, was southbound in the left lane of

Interstate 240 (I-240) in Memphis, Tennessee. (See figure 1.) The van was owned and

operated by Tippy Toes Learning Academy (Tippy Toes), a private child care1 center. A

witness driving behind the van stated that it was traveling about 65 mph when it drifted

from the left lane, across two other lanes, and off the right side of the roadway. (See figure

2.) She said that she did not see any brake lights. The van then overrode the guardrail and

continued to travel along the dirt and grass embankment until the front of the van collided

with the back of the guardrail and a light pole. The rear of the van rotated

counterclockwise and the front and right side of the van struck the bridge abutment at the

Person Avenue overpass before coming to rest. (See figure 3.) The distance traveled by the

accident van from the point where it left the shoulder of the roadway to the final collision

with the bridge abutment was approximately 189 feet. The driver was ejected through the

windshield and sustained fatal injuries. Four of the children sustained fatal injuries, and

two were seriously injured.

1 Child care includes both day care (preschool age children) and before- and after-school care. It does

not include home-based child care or Head Start.

Figure 1. Area map.
Factual Information 2 Highway Accident Report

Figure 2. Approximate path of van, indicated by the arrow (the roadway continues to 

curve beyond the bottom of the picture, where the van began its departure).

Figure 3. Van at final rest.
Factual Information 3 Highway Accident Report

Injuries

Table 1. Injuries.2

Medical and Pathological Information

The driver sustained multiple fractures to left ribs 1 through 9, skull fractures, a

shear injury to the brain stem, internal injuries, a fractured right ulna, and multiple

abrasions to the whole body. As for the fatally injured children, the 6-year-old girl

lap/shoulder belted in the right-front seat (see figure 4) sustained depressed skull fractures,

fractures of the lower extremities, and multiple contusions, lacerations, and abrasions to

the head and lower extremities. The unrestrained 8-year-old boy seated in the center of the

first row sustained a depressed fracture to the occipital bone, a right femur fracture, and

multiple abrasions and contusions. The unrestrained 6-year-old girl seated on the right

side of the first row sustained open, depressed skull fractures, a cervical fracture, and

multiple abrasions to her extremities. The unrestrained 9-year-old boy seated in the center

of the second row3 sustained skull fractures, a left rib fracture, a fracture to the right upper

extremity, and multiple abrasions.

Injuries Driver Passengers Total

Fatal 1 4 5

Serious 0 2 2

Minor 0 0 0

None 0 0 0

Total 1 6 7

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

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

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

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

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

more than 5 percent of the body surface.

3 The exact seating position of this passenger could not be determined. He had been in the center of the

second row prior to dropping off a passenger before the accident. After the drop-off, he may have moved

over, between seating positions 7 and 8 (figure 4). For the simulation, he was placed in the center seat.
Factual Information 4 Highway Accident Report

Two other children sustained serious injuries. An unrestrained 10-year-old boy

seated on the left side of the first row sustained upper torso fractures, internal injuries, and

facial lacerations and abrasions. Another unrestrained 10-year-old boy seated on the left

side of the second row sustained brain and lung injuries.

Survival Aspects

Intrusion and Restraints

The driver was not wearing his lap/shoulder belt and was ejected during the impact

with the bridge abutment. The impact with the light pole and bridge abutment pushed the

dashboard into the right-front passengerís seat, so that part of the dashboard was touching

Figure 4. Seating chart (*ejected; shading indicates fatal injury).

1* 2

3 4 5

6 7 8

9 10 11

12 13 14 15

Seat Age Belt Use Injury

1 Fatal

2

3

4

5

6

7

27

6

10

8

6

10

9

Lap/shoulder

None

None

Serious

None

None Serious

None

Fatal

Fatal

Fatal

Fatal

None
Factual Information 5 Highway Accident Report

the right front of the passengerís seat cushion. The A-pillar was pushed rearward into the

passenger compartment to a point 12 inches from the right-front passengerís seatback. The

floor pan under the right-front seat was deformed so that it also compromised the right-front

passengerís leg room. The right-side sliding door was crushed inward about 12 inches.

Because the van was configured so that the first three rows of rear seats were not adjacent to

the right side of the van, occupant space for the passengers in the rear was not compromised.

The vehicle had four rows behind the two front seats: three 3-passenger bench

seats followed by a 4-passenger bench seat. All seating positions were equipped with

passenger restraints: lap/shoulder belts in the front seats and outboard seating positions

and lap belts only in the center seating positions. Only the passenger in the right-front seat

was wearing a seat belt. The lap and shoulder portion of the seat belt had to be cut during

the emergency response. Both the driver and the passenger side had front airbags, which

deployed during the collision.

Emergency Response

An off-duty police sergeant witnessed the accident from the northbound lanes of I240. He stated that he immediately pulled onto the shoulder and ran across the southbound

lanes to the van. At 8:19 a.m., he notified the police traffic dispatcher via radio to send

emergency rescue equipment to the scene. The first police unit arrived at 8:21 a.m., and

the first fire and rescue unit arrived at 8:27 a.m.; rescue and extrication efforts were

completed by 8:47 a.m. The first ambulance departed the scene at 8:53 a.m., and three

other ambulances departed within the next 3 minutes. All four ambulances arrived at the

hospital between 9:03 a.m. and 9:08 a.m. A total of 23 police cars, 4 motorcycle units, and

23 firefighters and emergency medical technicians were deployed to the scene.

Toxicological Tests

Preliminary autopsy results for the driver indicated a positive screening test for

tetrahydrocannabinol (THC),4 the chief intoxicant in marijuana. The Civil Aeromedical

Institute conducted further toxicological testing on a sample of the driverís blood, which

revealed the presence of THC and THC carboxylic acid (THC-COOH).5

 The sample was

negative for alcohol and other illicit drugs or prescription medication.

 Driver Information

The 27-year-old driver held a valid Type D Tennessee driverís license with an F

endorsement. The Type D license permitted him to operate vehicles weighing less than

26,000 pounds or carrying fewer than 16 occupants (including the driver); the F

endorsement, obtained on November 6, 2001, allowed the driver to transport passengers

4 0.0602 μg/ml (micrograms per milliliter).

5 0.0445 μg/ml. THC-COOH is the primary inactive metabolite of THC.
Factual Information 6 Highway Accident Report

for compensation. The driverís record showed three registration violations in 1994. His

criminal record showed an arrest for disregarding a stop sign and possession of a

controlled substance on November 28, 2000. In connection with this arrest, the driver pled

guilty in December 2001 to possession of a controlled substance.

The driver applied to work at Tippy Toes as a driver on September 18, 2001, and

began work shortly thereafter. He did not submit a medical examination, and Tippy Toes

did not conduct a criminal background check, even though the Tennessee Department of

Human Services (TDHS) required both actions. Tippy Toesís driver employment

application did not request information on previous arrests or convictions.

According to the driverís fiancÈe, with whom the driver lived, he had gone to bed

the previous evening about 8:30 p.m. and awoke on the morning of the accident at

approximately 4:30 a.m. He normally went to bed between 8:00 and 9:00 p.m. and awoke

about 4:00 a.m. because he had to be at the child care directorís home at 5:00 a.m. to pick

up the van. He usually returned home shortly after 9:00 a.m., ate breakfast, and then took a

nap before leaving about 1:00 p.m. to pick up the van and complete the afternoon route.

Friends and coworkers described the driver as a ìnice guyî who loved children.

The driverís fiancÈe stated that the driver had been treated in the emergency room

for a cold several months before the accident and was tested for diabetes as part of his

followup care. The results were negative. The driver had no medical insurance, and,

according to his fiancÈe, only sought treatment for acute medical problems. An entry in the

driverís May 2001 medical records, made when the driver was treated for gastroenteritis,

also documented substance abuse. The driverís glucose levels in May 2001 and at a

followup in June 2001 were within normal limits. Postmortem blood tests indicated an

elevated hemoglobin A1c (HbA1c) level.6

 HbA1c level correlates with average blood

glucose levels over several months and is frequently used to monitor diabetes. The driver

was obese.7

 He was not taking any prescription medications at the time of the accident.

According to the driverís cousin (who was also a driver for Tippy Toes), the driver

was a regular marijuana user who often smoked before retiring for a nap between his

morning and afternoon runs. Several parents of children who rode in the van told

investigators that they had complained to the child care director that the driver had been

smoking marijuana in the van in the childrenís presence. A 12-year-old boy who had

departed the van prior to the collision told investigators that the driver had smoked

marijuana in the van in the past but had not done so in his presence on the day of the

accident. One of the two surviving children on the van told the Memphis Police

Department (MPD) that the driver did smoke a marijuana cigarette while he was driving

on the morning of the accident. The child also said the driver had smoked them on

previous occasions, and the child thought the owner of the child care center was aware of

6 The driverís HbA1c level was 8.6 percent. The normal range is 4.3 to 6.1 percent.

7 According to the National Institutes of Health, obesity is defined as a body mass index (the ratio of

weight to height squared times a constant factor) greater than 30; morbid obesity is defined as a body mass

index greater than 39. The driver was 6 feet 1 inch tall and weighed 380 pounds, corresponding to a body

mass index of 50.
Factual Information 7 Highway Accident Report

it. The owner/director of the child care center declined to be interviewed. Interviews

conducted by the MPD and Safety Board investigators indicated that the driverís

marijuana use was well known to friends and coworkers, who nicknamed him ìSmoky.î

Neither the child care center nor the TDHS had any record of complaints about the

driverís performance during the 6 months he had been employed by Tippy Toes.

An 11-year-old who regularly rode the van also told investigators that he had seen

the driver nod off while driving in the past. A day care worker who rode with the driver for

the first portion of the morning route as an attendant, starting between 6:00 and 6:30 a.m.

and getting off the van at the child care center at 8:00 a.m., told investigators that the

driver occasionally ìzoned outî and also nodded off when stopped at traffic lights. The

attendant believed that in addition to helping the children get settled in the van, ìkeeping

Smoky awakeî was her primary responsibility. The driverís cousin acknowledged that the

driver frequently nodded off at red lights, but stated that he had not seen the driver fall

asleep while driving. Another witness told investigators that when she went to the child

care center, she sometimes saw the driver seated in the van asleep and snoring. The

surviving child interviewed by the MPD said that the driver sometimes had a hard time

staying awake while driving and recalled trying to wake him.

Vehicle and Wreckage Information

The accident vehicle was a 1999 Ford Motor Company (Ford) E-350, 15-

passenger Club Wagon. Tippy Toes purchased the van with the intent of transporting

children to and from school and to and from home. The van had a gross vehicle weight

rating of 9,100 pounds, an original wheelbase of 132 inches, and an overall length of 232

inches. The vehicleís odometer read 98,860 miles. The van was powered by a 5.4-liter V-8

fuel-injected gasoline engine with a 4-speed automatic transmission and equipped with 4-

wheel antilock braking system (ABS), power steering, and cruise control.

Safety Board investigators examined the brakes and found that the right-rear inner

brake pad was below Fordís recommended wear limits and the corresponding brake rotor

was grooved. All other brake components were within recommended limits. The hydraulic

brake line and ABS sensor wire to the right-front brake were severed, consistent with

accident damage. The brake fluid in the reservoir was about 1 inch below the ìfullî mark.

The three rear brake light assemblies (left, center, and right) were removed and the

bulbs examined by Safety Board investigators. No sign of filament deformation was

present in any of the bulbs. The bulbs were reinstalled and the brake lights tested by

depressing the brake pedal. All brake light bulbs illuminated.

Both front tires and the left-rear tire had cuts and were deflated. The right-rear tire

was inflated to 55 psi. The label on the driverís doorsill recommended 55 psi for the front

tire and 80 psi for the rear.

The steering wheel was not deformed and rotated freely, moving the left-front tire

(investigators found the right drag link disconnected, so the right-front tire did not move).
Factual Information 8 Highway Accident Report

Due to the severity of the accident damage, investigators were unable to determine

whether the cruise control was on at the time of the accident.

Investigators extracted diagnostic codes from the vanís electronic crash sensor

(ECS), antilock brake module, and powertrain module. The codes that registered were

consistent with the crash event, according to Ford personnel. Siemens (the ECS

manufacturer) further analyzed the ECS because it has the capability of recording a crash

pulse. However, battery power to the ECS had been cut off before a complete crash pulse

could be written to the ECS. Five milliseconds of data were recorded; the remaining 65

milliseconds that are typically written were blank. No useful data could be extracted to

determine the crash pulse.

The vanís exterior had direct impact damage to the front, including the bumper, grill,

hood, lights, right-front fender, and a broken windshield. (See figure 5.) The base of the right

A-pillar was bent backwards approximately 15 inches to within 12 inches of the front seat.

The right side also had impact damage to both doors and the wheel well area. The maximum

crush to the right side was about 24 inches at the roofline. The direct damage extended about

195 inches from the right-front fender to the right-rear quarter panel. The left side had a bent

driver doorframe and body wrinkles in the front and rear wheel well areas. The front of the

roof was bowed upward. No damage occurred to the rear of the van. The wheelbase was 133

inches on the left and 124 inches on the right. The overall length of the van was 232 inches

on the left; this length was reduced to 224 inches on the right.

Figure 5. Van damage.
Factual Information 9 Highway Accident Report

The interior damage generally corresponded to the exterior damage along the right

side of the van. The front and side of the van intruded into the front seat passengerís space.

(See figure 6.) The lateral floor weld behind the front seats on the passenger side separated

and buckled upward.

Highway Information

 The accident events originated in the southbound lanes of I-240 in southwest

Memphis and concluded approximately 189 feet later on the north side of the Person

Avenue overpass. (See figure 7.) I-240 is an urban principal arterial highway and, in the

vicinity of the accident site, was a six-lane divided highway with concrete pavement. Each

side of the highway consisted of a 2.5-foot wide concrete drainage channel, an 8-footwide outside shoulder, three 12-foot-wide travel lanes, and a 13-foot-wide inside shoulder.

All pavement markings met the requirements specified in the Manual on Uniform Traffic

Control Devices.

8

Figure 6. Front passenger seat intrusion.

8 U.S. Department of Transportation, Federal Highway Administration, Manual on Uniform Traffic

Control Devices (Washington, DC: FHWA, 2000).
Factual Information 10 Highway Accident Report

A 2-foot-wide, 42-inch-high median concrete barrier separated the north- and

southbound traffic lanes. A 165-foot-long blocked-out W-beam (strong post) semirigid

longitudinal roadside barrier system (guardrail) was located about 2.5 feet west of the

right shoulder adjacent to the concrete drainage ditch on a 3:19

 grassy embankment and

was attached to the Person Avenue concrete bridge abutment. The southbound lanes had a

2.5-percent descending grade and the roadway transitioned from a straight alignment to a

3-degree horizontal left curve at a point 440 feet north of the beginning of the barrier. (See

Figure 7. Highway at accident site.

9 The embankment rose 1 foot for every 3 lateral feet away from the roadway.

0 10 20 40 60

FEET

N

Light pole 

 Travel

 lanes

Longitudinal 

roadside

barrier

Outside

shoulder

Bridge

abutment

Inside 

shoulder

Concrete 

median barrier

Person Avenue 

overpass

Milepost 

27.6
Factual Information 11 Highway Accident Report

figures 8 and 9.) A 38-foot-high aluminum light pole on a breakaway base was

approximately 20 feet north of the bridge abutment and about 4 feet west of the guardrail.

Figure 8. Overhead view of roadway curvature.

Figure 9. Roadway curvature from ground level.
Factual Information 12 Highway Accident Report

The posted speed limit on I-240 was 55 mph. When originally constructed, the

design speed of the highway was 50 mph; in 1993, the design speed was increased to 55

mph. No speed surveys had been conducted on I-240 in the vicinity of the accident site

between 1993 and the time of the accident. At the Safety Boardís request, the Tennessee

Department of Transportation (TDOT) conducted a speed survey in the vicinity of the

Person Avenue overpass on July 9, 2003, with six speed-monitoring stations (three in each

direction). The survey found that the 85th percentile speed was 70 mph, and the median

speed was 65 mph.

The average daily traffic count for I-240 in both the north- and southbound traffic

lanes was nearly 105,000 in 2001.

Barrier System

When I-240 was constructed in 1963 as a divided six-lane highway, no roadside

barriers existed at the Person Avenue overpass. A 1977 highway rehabilitation project

added a 150-foot-long guardrail along the interstate to shield the Person Avenue bridge

abutment from errant traffic. The barrier system included the use of an anchored-inbackslope terminal. In 1993, this guardrail at the Person Avenue overpass was replaced.

Since 2001, the roadside barrier adjacent to the Person Avenue overpass has been repaired

several times. Records from TDOT indicated that because of collision damage, the entire

barrier was replaced on May 29, 2001 (see Accident History section below), and again on

August 9, 2002, due to collision damage from this accident.

At the time of the accident, the barrier consisted of a terminal unit, a longitudinal

section, and a transition section between the longitudinal section and the abutment.

Located 3.5 feet from the drainage ditch, the terminal unit was an anchored-in-backslope

design consisting of a 36-inch-wide by 24-inch-long by 36-inch-deep concrete block

buried so that the top was almost at grade with the backslope. (See figure 10.) About 1

foot of the W-beam guardrail was affixed to the anchor block, of which about 5 inches was

exposed above ground. The W-beam guardrailís end treatment flared10 away from the edge

of the drainage channel, where the guardrail was 26 inches above ground. Despite the

apparent differences in height of the W-beam guardrail, the guardrail was horizontal

(parallel to the roadway surface) because of the backslope. The guardrail did not reach its

full height of 26 inches above the ground until it reached the drainage channel, 57 feet

beyond the terminal.

10 A roadside barrier is ìflaredî when it does not run parallel to the edge of the roadway. The design of

the anchored-in-backslope terminal necessitates the use of a flare to route the terminal into the backslope.
Factual Information 13 Highway Accident Report

The longitudinal section consisted of a 165-foot single W-beam guardrail; the

effective length was 160 feet, since 5 feet was attached to the bridge abutment. Metal posts

with wooden blockouts supported the W-beam guardrail.11 The posts were approximately

75 inches apart along the semirigid portion. The section prior to the bridge abutment

provided for the transition from a semirigid longitudinal section to a rigid section to

prevent pocketing.12 The posts along the rigid section of the barrier were closer together

(approximately 36 inches apart).

Accident History

TDOT and the MPD provided accident records for the section of I-240 near the

accident scene. For an area about 0.5 miles on either side of the accident location, TDOT

reported 1 fatal accident resulting in 1 fatality, 48 injury accidents resulting in 85 injuries,

and 91 accidents resulting in property damage only between 1997 and 2001. Of these

accidents, 43 (31 percent) involved collisions with fixed objects. The MPD accident data,

which encompassed an area at or near the accident site,13 reported a total of 34 accidents

between 1997 and 2001, 25 of which occurred in the southbound lanes. The MPD data

showed two fatal accidents similar to this accident. One occurred in 1998, when the driver

Figure 10. Guardrail and terminal unit.

11 A blockout offsets the W-beam from the vertical post and prevents vehicles from snagging on the

vertical posts.

12 Pocketing occurs when a vehicle makes sufficient encroachment into a barrier system to become

trapped instead of redirected.

13 Most of the accidents were less than one-tenth of a mile from the accident location, with the furthest

occurring one-quarter mile away.
Factual Information 14 Highway Accident Report

left the right side of the highway about 325 feet north of the Person Avenue overpass,

became trapped behind the roadside barrier, struck a light pole, and then struck the bridge

abutment. The second similar accident occurred in 2002. MPD records revealed two other

accidents in which the vehicle departed the right side of the highway and traveled behind

the roadside barrier. In both cases, the drivers were able to stop before colliding with the

bridge abutment.

Physical Evidence

No physical evidence was found in the roadway leading up to the vanís impact

with the roadside barrier. The first impact on the barrierís W-beam guardrail occurred 7

feet south of the terminal end of the W-beam guardrail. Adjacent to the first impact point

was a 21-foot-long tire furrow located in the grass median at a 6-degree angle from the

interstateís right shoulder. (See figure 11.) The damage extended along the top of the

guardrail for about 1.5 feet. About 16 feet south of the first contact point was a series of

scrapes along the W-beam guardrail, extending about 14 feet. The guardrail became

increasingly deformed, bent, and torn moving south along the guardrail. Other points of

damage along the guardrail included black discoloration, bends, and other damage.

Two additional tire furrows began about 4 feet west of the barrier and continued

south about 100 feet. Initially, the tire furrows were 8 inches apart, but at the point they

terminated they were 4.5 feet apart. A 15-foot section of the barrier adjacent to the

termination of the tire furrows had contact damage along the backside of the W-beam

guardrail. The support posts and blockouts were bent in a southerly direction, and the

attachment hardware had been pulled through the back of the W-beam guardrail. (See

figure 12.)
Factual Information 15 Highway Accident Report

Figure 11. Physical evidence.

Milepost

27.6

0 10 20 40 60 80 100

FEET

N

Person Avenue

overpass

Ford van

at final rest

Base of

light pole

Additional tire

furrows

Light pole

Roadway

departure

and tire

furrow

Beginning of

 scrapes to

 roadside

 barrier

First impact
Factual Information 16 Highway Accident Report

The 38-foot light pole was mounted on a 14-inch-square breakaway base14 located

at ground level. The light poleís mounting plate was connected to the breakaway base by

four 4.5-inch-long vertical nut and bolt assemblies. (See figure 13.) After the accident, the

light pole came to rest in the center lane of southbound I-240. The base of the breakaway

fixture was still in the ground; three of the four mounting nuts were still attached to the

base, but the mounting nuts had fractured as designed, separating the light poleís

mounting plate from the breakaway base. (See figure 14.) An indentation was noted 17.5

inches above the poleís mounting plate; scrapes and paint transfers extended from the

mounting plate to 57 inches above the plate.

Figure 12. Guardrail damage, light pole base (indicated by arrow), and bridge abutment 

scrapes.

14 A breakaway base is used so that if the object is struck, it moves instead of acting as a rigid barrier,

which could potentially cause more damage.
Factual Information 17 Highway Accident Report

Figure 13. Exemplar light pole plate and breakaway base.

Figure 14. Light pole breakaway base mounting plate with fractured mounting nuts.
Factual Information 18 Highway Accident Report

The north face of the bridge abutment had contact damage encompassing an area 8

feet high by 16 feet wide. At the base of the abutment, the earthen backslope was scarred,

and dirt was thrown against the abutment; dirt was compressed into the surface of the

concrete. Investigators observed a circular scrape mark 17 inches in diameter at the

bottom of the abutment about 18 inches west of the bridgeís northeast corner.

Weather Information

Observations from the Memphis International Airport, located approximately 4

miles southeast of the accident location, were clear with a temperature of between 43 and

46 degrees Fahrenheit and winds of about 15 mph from the northeast.

Operational Information

Tippy Toes Learning Academy was a TDHS-licensed child care provider for

children ages 6 weeks to 12 years. To supplement child tuition, Tippy Toes received money

from the TDHS, some of which was from the U.S. Department of Health and Human

Services (DHHS) for temporary assistance to needy families.15 The TDHS license permitted

transportation for local and intrastate travel. Students were typically transported from their

homes to Tippy Toes, from Tippy Toes to and from school, and from Tippy Toes to home.

Tippy Toes began operations in October 2000. On April 9, 2002, 5 days after the

accident, Tippy Toes ceased operation and voluntarily surrendered its license.

Tippy Toesís TDHS application identified a Dodge and two Fords as the vehicles

used for student transportation. The TDHS requires child care providers only to identify

vehicles by make. Tippy Toes purchased the 1999 accident van from a used car dealer on

October 4, 2001. No vehicle maintenance records or vehicle repair records were on file at

Tippy Toes, although both were required by TDHS regulation.

On its TDHS application, Tippy Toes identified three regular drivers and one bus

attendant. The accident driverís file included his September 18, 2001, application for

employment; the child care facility ownerís December 27, 2001, evaluation of the driver;16

a copy of his driverís license; and a February 23, 2002, certificate of training issued by the

TDHS for attending a 3-hour course on transportation rules and regulations, as was

required for all child care drivers. No records of a medical examination or a criminal

background check were found, even though the TDHS requires both. Further, these items

were never submitted to the TDHS, as was also required.

15 From the time Tippy Toes began operation in October 2000, until the time it ceased operation shortly

after the accident, Tippy Toes received $516,919 from the TDHS, $54,368 of which was allocated for child

transportation.

16 This document stated that the driverís ìÖevaluation went very well. He is aware of the rules and

policies, as far as he continuously to work in this facilities. [sic]î
Factual Information 19 Highway Accident Report

The TDHS requires that any child care center providing transportation maintain,

for 1 year, a passenger log showing the location and time at which a child was picked up

or dropped off and indicating the person present with or waiting for the child. Tippy Toes

maintained such a passenger log. The TDHS also required that a vehicle used to transport

children carry a fire extinguisher, emergency reflective triangles, a first aid kit, and a

bloodborne pathogen kit; none of these items were found in the accident van.

Additionally, the TDHS requires that staff responsible for regularly transporting children

practice emergency exiting procedures with the children.

As part of its oversight, the TDHS conducted at least six child care center site visits

per year to ensure compliance with all TDHS rules and regulations. If a child care center is in

violation of TDHS rules, the TDHS can require the center to enter into a Plan of Corrective

Action. The TDHS may also impose civil penalties and/or probation, deny the application for

licensure or relicensure, or suspend or revoke all or any part of the license to operate.

Tippy Toes received five on-site inspections during the time in which the accident

driver was employed.17 The transportation operation was examined during the January 3, 2002,

inspection. The TDHS inspection report indicated that the transportation logs were reviewed

with the director of Tippy Toes. No violations or discrepancies were noted in this report.

Simulations

Vehicle Dynamics Simulation

Safety Board staff conducted a simulation18 of the vanís dynamics during the

accident sequence to estimate the vanís speed and crash pulse and to determine where the

van departed the roadway. Based on witness statements, the van drifted off the roadway

with no steering or braking input. To match the physical evidence adjacent to the roadway,

the van was placed in the left lane near the beginning of the horizontal curve, with an

initial speed of 65 mph. In the simulation, the van traveled without added steering or

braking along the roadway in a path tangent to the curve, until the curvature and elevation

of the roadway caused the van to depart the left lane and cross two other lanes and the

shoulder. The simulation showed that based upon the vanís roadway departure when

starting in the left lane, the guardrail would have had to have been about 40 feet longer

with the same end treatment in order to redirect the van as it drifted off the roadway.

In the simulation, the van was traveling approximately 63 mph as it departed the

roadway. The vanís speed decreased as it interacted with the guardrail end treatment and

traveled along the grass; immediately before impacting the backside of the guardrail posts

17 These inspections, which were performed by different people, occurred between December 18, 2001,

and March 7, 2002.

18 The Human Vehicle Environment (HVE), Simulation Model Non-linear (SIMON), Engineering

Dynamics Corporation Simulation of Automobile Collisions (EDSMAC4), and Engineering Dynamics

Corporation Reconstruction of Accident Speeds on the Highway (EDCRASH) software programs were used

for the simulation.
Factual Information 20 Highway Accident Report

and light pole, the van was traveling about 56 mph. According to the Insurance Institute

for Highway Safety,19 most frontal airbags will deploy in crashes when the longitudinal

change in velocity is 16 mph or more. Upon impact with the bridge, the vanís speed

decreased another 30 mph, with some residual velocity remaining as the van continued to

rotate and rebound off the abutment. Simulation results showed the instantaneous

deceleration was 12.4 g during impact with the guardrail posts and light pole and 31.1 g

during impact with the bridge abutment.

Occupant Kinematics Simulation

The Safety Board conducted a simulation of the occupant movement within the

vehicle to determine the possible kinematics that led to injury and ejection and to compare

the effect of the use of restraints among occupants. The simulation used output from the

vehicle dynamics simulation to establish the crash pulse and the position-time history and

deformations of the van. The MAthematical DYnamical MOdels (MADYMO)20 program

was used to determine occupant kinematics and predicted injuries. Each simulation began

immediately prior to impact with the guardrail and light pole and continued until the van

rebounded from the bridge abutment.

The driver was simulated using a 95th percentile Hybrid III dummy,21 while each

child was represented by a 6-year-old Hybrid III dummy.22 Three simulations were

performed:

ï Actual restraint condition (simulates the 6-year-old in the front seat being

restrained by the lap/shoulder belt);

ï Available restraint condition (simulates restraints available in the accident van:

lap/shoulder belts for the outboard seats and lap belts only for the center

seating positions); and

ï Recommended restraint condition, first bench seat only (simulates booster

seats23 for the 6-year-old and 8-year-olds and lap/shoulder belt use for the 10-

year-old).24

19 <http://www.highwaysafety.org/safety_facts/qanda/airbags.htm>.

20 TNO MADYMO Automotive, MADYMO version 6.1.

21 The 95th percentile Hybrid III dummy, the largest validated dummy available for simulation, is 6

foot 2 inches tall and weighs 223 pounds, significantly less than the driverís weight of 380 pounds.

22 While some of the children were larger than the 6-year-old dummy, the Hybrid III 10-year-old

dummy has not yet been included in Federal regulations. The currently available 10-year-old dummy does

not have the additional measurement capabilities that the Hybrid III 6-year-old dummy has and thus was not

used.

23 The simulated booster seat was developed and validated by the University of Virginia Center for

Applied Biomechanics: L. Van Rooij, C. Sherwood, J. Crandall, K. Orzechowski, and M. Eichelberger,

Society of Automotive Engineers, The Effects of Vehicle Seat Belt Parameters on the Injury Risk for

Children in Booster Seats, 2003-01-0500 (Warrendale, PA: Society of Automotive Engineers, 2003).

24 The 6-year-old occupant in the front passenger seat was not simulated in a booster seat because

children 12 and under should not sit in the front seat.
Factual Information 21 Highway Accident Report

In the actual restraint condition, the occupants initially traveled forward and

laterally toward the left as the front of the van impacted the light pole and guardrail posts

and rotated counterclockwise, moving the occupants out of their normal seating positions.

During the impact with the bridge abutment, the occupants moved forward, then laterally

toward the right side of the van, impacting the intruded side, as the van rotated about the

front axle and impacted the abutment along the right side. The driver was ejected during

the impact with the bridge abutment.

In the available restraint condition, the occupants did not move as much as during

the actual restraint condition, but the type of restraint available affected their motion

during the impact with the guardrail and light pole. For lap/shoulder-belted occupants on

the left side of the van, the shoulder harness restrained their upper bodies, but began to

ride along the neck for the smaller occupants. For those in the center, where only lap belts

were available, the upper body was free to rotate forward and to the left. The same was

true for the occupants in the right side of the vehicle, whose upper bodies slid out of the

harnesses as they moved forward and toward the left. During the impact with the bridge

abutment, simulated passengers on the right and in the center were out of position from the

initial impact and traveled a greater distance toward the right side, as compared with their

initial positions, before impacting the intruding sidewall and window structure.

In the recommended restraint condition, only the 6- and 8-year-old occupants in

the first bench seat were simulated in booster seats using 6-year-old Hybrid III dummies,

as they were the only passengers, based on age and weight, recommended to use booster

seats.25 The booster functioned as intended, helping to position the lap and shoulder belt

on the occupant and helping the restraint remain in position during the crash sequence.

(See figure 15.) Furthermore, the booster helped reduce the lateral motion of the

occupants during the initial phase of the crash. As a result, the upper body did not have as

far to travel to the right during the impact with the bridge abutment, reducing the severity

of the impact with the intruding sidewall and windows. Without the booster seats, the

location of the attachment points for the lap/shoulder belts positioned the shoulder harness

higher on the 6-year-old torso. (See figure 15, right dummy.)

To provide a comparison of the shoulder belt positioning on a 10-year-old, the

currently available 10-year-old dummy was placed in the MADYMO model and fitted

with the lap/shoulder belt in the manner simulated for the Hybrid III 6-year-old dummy in

the front seat. (See figure 16.)

25 (a) National Transportation Safety Board, Analysis, Vol. 1 of The Performance and Use of Child

Restraint Systems, Seatbelts, and Airbags for Children in Passenger Vehicles, Safety Study NTSB/SS-96/01

(Washington, DC: NTSB, 1996), 2 Vols. (b) <http://www.nhtsa.dot.gov/CPS/>.
Factual Information 22 Highway Accident Report

Figure 15. Seat belt position with and without a booster 

seat (6-year-old Hybrid III dummy).

Figure 16. 10-year-old dummy with lap/shoulder belt.
Factual Information 23 Highway Accident Report

Bus Definitions

School Bus

The Federal Motor Vehicle Safety Standards define school bus as a vehicle that

carries more than 10 people, including the driver, that is used primarily to transport

children to or from school. In the early 1970s, the Federal Government developed

additional design standards for school buses specifically addressing occupant protection,

joint strength of the body panels, and roof rollover protection. The stricter occupant crash

protection standards for school buses assure their passengers a higher degree of safety

than do Federal standards for other types of vehicles, including 15-passenger vans. Small

school buses (those with gross vehicle weight ratings of less than 10,000 pounds) must

meet the same structural standards as large school buses and, in addition, must be

equipped with lap or lap/shoulder belts at all passenger seating positions.

Multifunction School Activity Bus

On July 31, 2003, the National Highway Traffic Safety Administration (NHTSA)

established a new school bus classification, the multifunction school activity bus

(MFSAB), for use on trips other than between home and school. This new classification

provides entities other than schools, such as child care centers or Head Start centers, with

an alternative to 15-passenger vans. The MFSAB is built to the same crashworthiness and

occupant protection standards as a school bus, but is not required to have flashing lights or

stop arms since most MFSABs drop off and pick up passengers at the destination rather

than in the street.

School Bus Fatality Data

The Safety Board examined Fatality Analysis Reporting System (FARS)26 data for

school buses and large (12- and 15-passenger) vans. The data showed that from 1993

through 2002, 57 fatalities occurred among occupants younger than age 19 in school buses

and 574 fatalities occurred among occupants younger than age 19 in large vans (12- and

15-passenger vans). More than 435,000 school buses27 and about 500,000 15-passenger

vans are on the road.28

26 FARS, maintained by NHTSA, is a census of all crashes involving a motor vehicle traveling on a

traffic way customarily open to the public that result in the death of a person (occupant or nonmotorist)

within 30 days of the accident.

27 School Transportation News, <www.stnonline.com>.

28 National Transportation Safety Board, Evaluation of the Rollover Propensity of Fifteen-Passenger

Vans, Safety Report NTSB/SR-02/03 (Washington, DC: NTSB, 2002).
Factual Information 24 Highway Accident Report

Child Care Transportation Laws and Guidance

Over 117,000 child care centers29 in the United States30 provide care for millions of

children from ages 0 to 13 on a full-time or part-time basis. These child care centers must meet

regulations established by their respective States. In Tennessee, 4,908 child care providers care

for over 300,000 children. Among the 3,553 child care centers in Tennessee, 1,328 provide

transportation, the majority of which occurs between the centers and schools.31

The Federal Government funds over $4.8 billion32 annually to the States to help

subsidize child care for low-income families.

Findings of Tennessee Committee on Child Care Agency Transportation 

Safety

Following this accident, the Governor of Tennessee appointed a committee to

assess Tennesseeís child care transportation policies and to issue recommendations to

improve the safety of child care transportation. The committee recommended the

following:

ï Require that all vehicles purchased by child care providers meet the Federal

regulations for school buses and phase out the use of other vehicles by January

1, 2005;

ï Require the Tennessee Department of Safety to inspect all school-bus-type

vehicles used by child care centers as regular school buses;

ï Require children and the driver to be secured in individual passenger restraint

devices at all times and children under 4 to use child passenger restraints;

ï Require child care transportation drivers to have commercial driversí licenses;

ï Require child care transportation drivers to pass a yearly physical and mental

examination;

ï Require prospective child care transportation drivers to have completed a

criminal background check before being permitted to drive a child care

vehicle; and

ï Require that child care vehicles be identified with the name and phone number

of the child care center, a serial number registered with the TDHS, and a TDHS

number to call to make complaints.

29 These centers do not include Head Start programs, which provide educational programs for lowincome, prekindergarten children.

30 <www.thechildrensfoundation.net>.

31 Correspondence with TDHS Licensing Office dated February 12, 2004.

32 <www.acf.hhs.gov>.
Factual Information 25 Highway Accident Report

Child Care Transportation Laws in Tennessee

After the release of the Tennessee Governorís findings on child care agency

transportation safety, Tennessee law changed as noted below:

Vehicle standards. Beginning January 1, 2007, all vehicles used for child care

transportation and designed to carry more than 10 passengers must meet Federal school

bus standards.

Vehicle inspection. Beginning January 1, 2004, all vehicles used for child care

transportation must receive regular inspections and maintenance by a certified mechanic,

and all vehicles designed to carry more than 10 passengers must have an annual safety

inspection conducted by the Department of Safety. Inspection documentation must be

maintained by the child care center.

Restraints. Beginning January 1, 2007, all children must be restrained in ageappropriate restraints, and children weighing 40 to 80 pounds must be in booster seats.

Driver licensing. The State reiterated the existing requirement that child care

transportation drivers have a current Tennessee driverís license with an ìFî (for hire)

endorsement, or a license for the type of vehicle used.

Driver training. Beginning January 1, 2004, child care transportation drivers must

obtain a certification document from the Department of Safety signifying that they have passed

additional written or skills tests required for persons driving a vehicle transporting children

enrolled in child care. Furthermore, these drivers must obtain annual school bus driver training.

Driver physical. The State reiterated the existing requirement that child care

transportation drivers obtain an annual health statement signed by a physician verifying

that they are physically and mentally able to transport children.

Drug testing policy. Beginning August 1, 2003, all newly hired child care

transportation drivers must have a drug screen within 10 days of assuming duties and

beginning January 1, 2004, all existing drivers must have a drug screen. The child care

center must immediately review the results, and, if the results are positive, notify the

TDHS and prohibit the individual from driving for the child care center. Further, a written

plan approved by the TDHS must be established that prohibits the individual from driving

until he or she passes a drug test or is approved for driving by the TDHS.

Vehicle identification. Beginning March 1, 2003, all vehicles operated by child

care centers must be identified with their name, emergency contact number, and the label

ìChild Care Transportation Complaints,î followed by the TDHS phone number. This

identification must be on both sides and on the rear of the vehicle.

Child Care Transportation Laws in Other States

Safety Board staff reviewed child care transportation laws in other States to

determine how they compare with Tennesseeís new regulations. These laws are discussed

below and summarized in table 2 at the end of this section.
Factual Information 26 Highway Accident Report

Vehicle standards. Seven States require the use of school buses for at least some

child care transportation:

ï Hawaii requires that school buses be used for transportation to and from school;

ï Indiana requires that any vehicle carrying more than 10 children be a school bus;

ï Massachusetts requires that any child care vehicle carrying more than eight

children to or from school be a school bus;

ï New Jersey requires that school buses be used for early childhood centers if the

vehicle carries more than eight passengers but allows other vehicles for schoolage children;

ï New York requires that any new vehicle to be used for carrying more than 10

children to or from school be a school bus;

ï South Carolina will require, beginning January 1, 2006, that all vehicles carrying

more than 10 passengers to or from school meet school bus standards; and

ï Vermont requires private vehicles that are used to transport children to or from

school for compensation and that carry more than 11 passengers, including the

driver, be school buses. Vermont is the only State that notes in its child care

center guidelines the NHTSA requirement that a vehicle used primarily for

transportation to or from school must be a school bus.

Vehicle inspection. Twenty-eight States have an annual or biannual vehicle

inspection program.

Restraints. Forty States specify restraint usage requirements, many of which are

patterned after their child restraint laws.

Driver licensing. All State child care agencies require child care transportation

drivers to hold a driverís license appropriate for the vehicle used.

Driver training. One State, Maine, requires additional child care transportation

training within 6 months of employment.

Driver physical. Two States, Florida and Illinois, specifically require physical

exams before employment as a child care transportation driver. Florida requires an annual

physical examination that grants medical approval to a driver. Illinois requires that a driver

demonstrate physical fitness by submitting a medical exam from a licensed physician; this

medical form must be submitted to the Illinois Department of Children and Family Services.

Drug testing policy. Twenty-four States specifically prohibit drug use for child care

transportation drivers, and Arkansas, Indiana, and Montana require testing ìfor cause.î Only

Tennessee requires preemployment drug testing for child care transportation drivers.

Vehicle identification. Oklahoma is the only State besides Tennessee that requires

child care vehicles to be visibly marked with the name of the facility or sponsoring

organization.
Factual Information 27 Highway Accident Report

Table 2. Child care transportation laws. (Check mark indicates that the Stateís law 

addresses a particular area.)

Vehicle 

standards

Vehicle

inspection Restraints

Driver

licensing

Driver

training

Driver

physical

Drug testing

policy

Vehicle

identification

Alabama ! ! !

Alaska ! !

Arizona ! ! !

Arkansas ! ! !

California ! !

Colorado ! ! !

Connecticut !

Delaware ! ! !

District of

Columbia

!

Florida ! ! ! ! !

Georgia ! ! !

Hawaii ! ! !

Idaho ! !

Illinois ! ! ! !

Indiana ! ! !

Iowa ! ! !

Kansas ! ! ! !

Kentucky ! ! !

Louisiana ! ! !

Maine ! ! ! !

Maryland ! ! !

Massachusetts ! ! ! ! !

Michigan ! ! !

Minnesota ! ! !

Mississippi ! ! ! !

Missouri ! ! ! !

Montana ! ! !

Nebraska ! !

Nevada !

New Hampshire ! ! ! !

New Jersey ! ! ! ! !

New Mexico ! ! !

New York ! ! ! !
Factual Information 28 Highway Accident Report

Head Start Transportation Law

Head Start is a Federal child development program serving low-income children

from birth to age 5 to increase their school-readiness. On January 18, 2001, the DHHS,

which administers the program, issued a rule, partially based on a Safety Board

recommendation,33 concerning the transportation of children by Head Start agencies.

Beginning January 18, 2006, Head Start agencies providing transportation to children

enrolled in their programs must use school buses or allowable alternative vehicles that are

equipped with height- and weight-appropriate restraint systems; these restraint systems

must be used at all times. Effective January 20, 2004, one bus monitor must be on board

Head Start agency vehicles at all times. Further, all drivers must possess a commercial

driverís license and be examined by a licensed doctor to establish their physical ability to

perform the job. Finally, all drivers and monitors must receive recurrent training in vehicle

and passenger safety.

Vehicle 

standards

Vehicle

inspection Restraints

Driver

licensing

Driver

training

Driver

physical

Drug testing

policy

Vehicle

identification

North Carolina ! ! !

North Dakota ! !

Ohio !

Oklahoma ! ! ! !

Oregon ! !

Pennsylvania ! ! !

Rhode Island ! !

South Carolina ! ! ! !

South Dakota ! !

Tennessee ! ! ! ! ! ! ! !

Texas ! ! !

Utah ! ! !

Vermont ! ! ! ! !

Virginia ! ! !

Washington ! ! !

West Virginia ! ! !

Wisconsin ! ! !

Wyoming ! ! !

33 Safety Recommendation H-99-20, which recommended that Head Start children be transported in

vehicles built to Federal school bus structural standards or the equivalent, was classified ìClosedó

Acceptable Actionî on April 18, 2001. For further information, see National Transportation Safety Board,

Pupil Transportation in Vehicles Not Meeting Federal School Bus Standards, Special Investigation Report

NTSB/SIR-99/02 (Washington, DC: NTSB, 1999).
Factual Information 29 Highway Accident Report

National Highway Traffic Safety Administration Interpretation

All new vehicles used to transport children to or from school or school-related

activities must meet the safety standards for school buses.34 The Federal Motor Vehicle Safety

Standards require that school buses have roof rollover protection, energy-absorbing seats, and

greater body joint strength than most other types of vehicles, including 15-passenger vans.

NHTSAís Chief Counsel issued an interpretation letter35 on August 3, 1998, in

response to an inquiry for clarification from the Iowa Department of Education. In the letter,

NHTSA stated that using a vehicle to pick up children from school every day, or even every

other day, constitutes ìsignificantî use of a vehicle and that such a vehicle would be

considered a school bus and thus would need to comply with school bus requirements.

Booster Seats

NHTSA conducted a study36 in 1994 that examined lap/shoulder belt fit on

children. The study found that when children are seated upright, the widest part of their

calves rests on the edge of the seat, putting pressure on their legs and causing discomfort.

This discomfort often causes children to slouch, so that their legs hang over the edge of the

seat. One of the benefits of booster seats is that they allow children to sit comfortably

without slouching. Slouching can cause the lap belt to ride up on the abdomen and allow

the shoulder portion of the belt to cross close to the face. NHTSA concluded that the

minimum size child who could use a three-point belt alone would be 59.2 inches tall and

weigh 82 pounds. NHTSA currently recommends that a belt-positioning booster seat be

used for children ages 4 to 8 and under 4 feet 9 inches tall.37 NHTSAís position is

consistent with the Safety Boardís 1996 research38 and resulting recommendations

described in Appendix B, Previous Recommendations.

Roadside Barrier Guidelines

TDOT has adopted the American Association of State Highway and

Transportation Officialsí (AASHTOís) guidelines for terminal requirements and ìlength

of needî39 for roadside barriers. According to AASHTOís Roadside Design Guide,

40 when

34 Title 49 United States Code 30112.

35 < http://www.nhtsa.dot.gov/cars/rules/interps/files/17730.drn.htm>.

36 U.S. Department of Transportation, National Highway Traffic Safety Administration, Study of Older Child

Restraint/Booster Seat Fit and NASS Injury Analysis, DOT HS 808 248 (Washington, DC: NHTSA, 1994).

37 <www.nhtsa.dot.gov/CPS>.

38 NTSB/SS-96/01.

39 ìLength of needî is the length of barrier needed to protect an errant vehicle from impacting a

roadside hazard.

40 American Association of State Highway and Transportation Officials, Roadside Design Guide,

(Washington, DC: AASHTO, 1989), pages 5-32 ñ 5-39.
Factual Information 30 Highway Accident Report

determining a barrierís length of need, several factors should be considered, the primary

ones being the lateral distance of the hazard from the edge of the traveled way41 and the

theoretical distance that a vehicle leaving the roadway would need to come to a stop.42 In

the Roadside Design Guide, AASHTO notes that the equation for length of need is

intended for use on straight or nearly straight sections of roadway. The Roadside Design

Guide also notes that a vehicle leaving the roadway on the outside of a curve would follow

a tangential runout path, and in such cases, recommends that the tangent line from the

curve to the outside edge of the hazard or clear zone be used in place of the theoretical

runout path. TDOT guidance recommends the use of ìgood engineering judgmentî when

a hazard appears on the outside of a roadway curve and refers the designer to the

AASHTO Roadside Design Guide.

The anchored-in-backslope terminal design was deemed acceptable for use43 with

W-beam guardrails after October 1, 1998. According to the Federal Highway

Administration (FHWA), when properly designed, this type of terminal provides full

shielding for the identified hazard, eliminates the possibility of an end-on impact with the

barrier terminal, and minimizes the likelihood of access behind the rail.

Previous Recommendations

The Safety Board has addressed the issues of child restraints and school bus

occupant protection standards in previous reports. Appendix B summarizes relevant safety

recommendations that have been issued as a result of these reports and their status.

41 Distance measured to the far side of the hazard, if the hazard is a fixed object, or distance measured

to the outside edge of the clear zone, if the hazard is an embankment or if the hazard is a fixed object but

extends beyond the clear zone.

42 Referred to as ìrunout length,î this theoretical distance is measured from the upstream extent of a

hazard, along the roadway, to the point at which a vehicle is assumed to have left the roadway. The runout

length varies depending on the operating speed and the available friction between the tires and the ground.

43 FHWA Acceptance Letter CC-53 HNG-14, dated July 10, 1998.
31 Highway Accident Report

Analysis

Introduction

This report is the Safety Boardís fourth in a series of investigations to focus on 15-

passenger van transportation.

The first report,44 issued in 1999, addressed the use of vehicles that do not meet

school bus structural standards, yet are used for school, Head Start, or day care

transportation. The Safety Board found in the four accidents investigated, including one

involving a 15-passenger van transporting children to their homes from an after-school

child care program, that had school buses been used, the vehicles probably would have

sustained less damage and the passengers may have suffered fewer and less severe

injuries. In that report, the Board made recommendations to the States to require school

buses for all pupil transportation, including child care centers. (For more information, see

the Child Care Transportation section later in this analysis.) The Board also discussed the

importance of using age-appropriate restraints for all passengers, regardless of vehicle

type or use.

In 2002, the Safety Board issued a report45 that reviewed accident data for 15-

passenger vans. The Board found that 15-passenger vans have a greater propensity for

rollover than passenger cars, particularly when loaded with 10 or more passengers. The

Safety Board recommended that technologies to prevent rollovers, such as electronic

stability control, be developed and installed in 15-passenger vans. Additionally, the Board

recommended that 15-passenger vans be rated on their rollover propensity.

In 2003, the Safety Board issued a report46 on 15-passenger vans based on two

accidents involving church groups. The Board found that the vans handle differently than

passenger cars and require additional skills and knowledge to operate, particularly in

emergency situations. Additionally, the Board found that the vans are not built to the same

structural standards as school buses or even some passenger cars. The report also

discussed the importance of regular maintenance and the benefits of using seat belts to

prevent ejection.

In part, as a result of the Safety Boardís efforts, the public is more aware of the

safety shortcomings of 15-passenger vans. Head Start is phasing out use of the vans.

Several States already prohibit or have introduced legislation either prohibiting the use of

vans for school transportation or requiring drivers to obtain specific training for the vans.

44 NTSB/SIR-99/02.

45 NTSB/SR-02/03.

46 National Transportation Safety Board, 15-Passenger Van Single-Vehicle Rollover Accidents,

Henrietta, Texas, May 8, 2001, and Randleman, North Carolina, July 1, 2001, Highway Accident Report

NTSB/HAR-03/03 (Washington, DC: NTSB, 2003).
Analysis 32 Highway Accident Report

Some insurance companies are no longer insuring the vans for use by churches. General

Motors Corporation and Ford Motor Company have equipped their 15-passenger vans

with electronic stability control. NHTSA has developed an action plan for 15-passenger

vans that focuses on the vansí rollover propensity, construction, seat belts, statistics,

training, and consumer information. Finally, some groups that use 15-passenger vans, such

as churches, day care associations, and youth organizations, have issued press releases to

their members describing the problems associated with 15-passenger vans and possible

solutions, including phasing out their use.

The analysis that follows will first exclude factors not causal to the accident and

then describe the accident sequence. The remainder of the analysis will examine the

driverís physical condition, child care oversight in Tennessee and throughout the country,

and barrier design guidelines.

Accident Discussion

The weather was clear and the roadway dry. Safety Board investigators found no

mechanical defects on the van that would have contributed to the accident. The first

responder arrived at the accident scene within 2 minutes of the accident, and rescue and

extrication efforts were completed within 30 minutes of the accident. Therefore, the Safety

Board concludes that neither the weather nor the mechanical condition of the van

contributed to the accident and that the emergency response was timely and appropriate.

Just before the accident, the van had been traveling in the left lane of three lanes on

the southbound side of I-240. No other vehicles or obstacles were in the roadway that

would have caused the driver to depart his lane and begin moving toward the right

shoulder across two other lanes at a shallow angle. The roadway curved toward the left,

whereas the van continued in a straight path, departing the roadway at an approximate 6-

degree angle. (See figure 2 at the beginning of this report.) Physical evidence indicated no

skid marks from the van as it left the roadway.

The van traveled across the right shoulder, through the drainage channel, and onto

the grassy backslope. (See figure 17, location 1.) The right-front tire rolled over the Wbeam guardrail of the roadside barrier system, approximately 8.5 feet south of the barrierís

buried-in-backslope terminal; at this location, the W-beam guardrail was about 5 inches

above the ground. The van continued over the top of the barrier system (location 2) and

traveled about 40 feet, when the left-front tire rolled over the top of the W-beam guardrail

(location 3); the height of the guardrail at that point was about 14 inches.47 The vehicle

also began to rotate to the left, as evidenced by the two right tire furrows in the grass,

offset by 8 inches, and then began to roll toward its left side. The van continued for about

85 feet parallel to the roadway (location 4). The 3:1 slope of the grassy backslope caused

the van to be redirected back toward the roadside barrier, such that the left-front of the van

contacted the back of the barrier system about 133 feet south of the barrier terminal. The

47 Its final height was 26 inches above the roadway.
Analysis 33 Highway Accident Report

van had rotated approximately 19 degrees toward the right and collided with the light pole

affixed to a breakaway base unit (location 5). This collision caused the van to rotate

further, such that it was oriented about 45 degrees from the initial direction of travel when

it struck the bridge abutment, about 20 feet beyond the light pole (location 6). The front

right side of the van sustained the greatest amount of damage due to the force of the

collision. Because the van had begun to roll back toward the right after the collision with

the light pole, the upper portion of the right side body panels incurred the greatest impact

deformation.

Driverís Condition

The driverís condition was evaluated to determine the role that it played in the

accident. The driverís postaccident toxicological tests indicated that he had used

marijuana recently; based on the concentration of THC and THC-COOH in the driverís

blood, the estimated time of marijuana consumption was anywhere from 13 minutes to 3

hours before the accident.48 Since THC begins to metabolize almost immediately after use,

the presence of THC in the driverís blood indicated that the hallucinogenic compound of

marijuana had not completely metabolized and was still influencing the driverís

performance.

Figure 17. Path of van.

48 Based on data in M.A. Huestis, J.E. Henningfield, E.J. Cone, ìBlood Cannabinoids II. Models for the

Prediction of Time of Marijuana Exposure from Plasma Concentrations of ∆9

-tetrahydrocannabinol (THC)

and 11-nor-9-carboxy-∆9

-tetrahydrocannabinol (THCCOOH),î Journal of Analytical Toxicology, Vol. 16

(1992): 283-290.
Analysis 34 Highway Accident Report

Witness statements further support marijuana use. An attendant said she boarded the

van between 6:00 and 6:30 a.m. and left the van at about 8:00 a.m. and during that time did

not see the driver smoke. Therefore, the driver most likely smoked the marijuana either

before picking up the attendant or after dropping her off. Furthermore, one of the surviving

passengers told police that the driver was smoking marijuana while driving that morning.

Therefore, the Safety Board concludes that the driver consumed marijuana on the morning

of the accident and was under the influence of the drug at the time of the crash.

THC acts within the central nervous system and can result in mood changes and

disturbances in time perception.49 THC decreases dynamic visual acuity,50 reduces eyehand and hand-hand coordination, increases reaction times, causes incorrect reactions,51

can result in incorrect estimates of time and distance, and can increase brake time.52

According to the driverís fiancÈe, the driver slept his usual amount, about 8 hours,

on the night before the accident. He also routinely napped for a few hours at midday.

Witnesses told investigators that the accident driver sometimes dozed off when stopped at

traffic lights and was seen sleeping in his van while parked outside the child care center.

One witness said she could hear him snoring loudly from outside the van when it was

parked outside the day care center. Research suggests that napping is a common practice

among individuals with severe sleep apnea,53 a common disorder in which breathing stops

during sleep for 10 seconds or more, sometimes more than 300 times a night. Because of

these disruptions to normal sleep patterns, individuals with sleep apnea tend to suffer from

excessive daytime sleepiness, no matter how much sleep they obtain during any period.

A study of 384 patients with sleep apnea syndrome identified situations that have a

high tendency to induce sleep in these individuals.54 Riding in a car was reported as likely

to induce sleep in 71 percent of individuals with sleep apnea syndrome, and 50 percent

reported ìdrivingî as being sleep-inducing. Thirty-two percent of the apneic patients

reported falling asleep while waiting for a red light.

Another study55 compared 78 morbidly obese people without obstructive sleep

apnea with 40 healthy weight subjects and found that sleep problems were significantly

49 T.H. Barnes, Drug Use and Driving (Toronto: Addiction Research Foundation, 1974).

50 B. Brown, A.J. Adams, and G. Haegerstrom-Portnoy, ìEffects of Alcohol and Marijuana on Dynamic

Visual Acuity,î Perception and Psychophysics, Vol. 20, No. 2 (1975): 119-124.

51 P. Kielholz, V. Hobi, D. Ladewig, P. Miest, and R. Richter, ìAn Experimental Investigation About the

Effect of Cannabis on Car Driving Behavior,î Pharmakopsychiatrie Neuro-Psychopharmakologie, Vol. 6,

No. 2 (1973): 91-103.

52 B.J. Rafaelsen, P. Bech, and L. Rafaelsen, ìSimulated Car Driving Influenced by Cannabis and

Alcohol,î Pharmakopsychiatrie Neuro-Psychopharmakologie, Vol. 6, No. 2 (1973): 71-83.

53 R. Rosenthal, C. Bishop, P. Guido, M. L. Syron, T. Helmus, F. M. Rice, and T. Roth, ìThe

Sleep/Wake Habits of Patients Diagnosed as Having Obstructive Sleep Apnea,î Chest, Vol. 111, No. 6

(1997): 1494-1499.

54 T. Roehrs, M. A. Carskadon, W. C. Dement, and T. Roth, ìDaytime Sleepiness and Alertness,î eds.

M. H. Kryger, T. Roth, and W. C. Dement, Principles and Practice of Sleep Medicine, 3rd ed. (Philadelphia:

W. B. Saunders Co., 2000): 43-52.
Analysis 35 Highway Accident Report

more frequent in the obese people. Excessive daytime sleepiness was reported by 34.7

percent of the obese patients and by 2.7 percent of the normal weight subjects.

Sleep apnea is characterized by excessive daytime sleepiness, despite an

apparently sufficient period of night sleep.56 The driverís obesity57 and snoring are both

risk factors for a sleep disorder, which can cause excessive daytime sleepiness.

Furthermore, diabetes has been linked to obstructive sleep apnea,58 and, while

undiagnosed, the driver had elevated HbA1c levels that would indicate a diabetic

condition. The driver had never undergone a formal evaluation for a sleep disorder;

however, he exhibited the symptoms and risk factors for a sleep disorder.

The driver of the Tippy Toes van was transporting child care children to school on

the day of the accident. He had been driving for Tippy Toes for just over 6 months without

a record of complaints about his performance on file with the day care center, despite the

fact that several parents said they had complained to the director of Tippy Toes about the

driverís marijuana use. Two children who rode with the driver regularly, another child care

worker (the attendant), and the driverís cousin, who was also employed as a driver by

Tippy Toes, told Safety Board investigators that the driver nodded off while stopped at

traffic lights. The attendant also said that coworkers and friends were well aware of the

driverís marijuana use and that she believed the owner and director of the child care center

were aware as well.

A witness behind the van reported the absence of illuminated brake lights as the

van departed its travel lane, crossed the center and right lanes, and left the roadway. The

van departed at a shallow angle from the roadway, and no skid marks or other evidence of

braking or steering could be found. Further, the bulbs in the rear brake light assemblies

showed no sign of filament deformation, indicating that the brake lights were not on at the

time of the crash, consistent with the driver not reacting to the roadway departure. Based

on the simulation, more than 3 seconds elapsed from the time the van departed the left lane

to the time the van was on the grass, sufficient time59 for the driver to notice the lane

departure and react by either steering or braking.

55 O. Resta, M.P. Foschino-Barbaro, P. Bonfitto, T. Giliberti, A. Depalo, N. Pannacciulli, and

G. De Pergola, ìLow Sleep Quality and Daytime Sleepiness in Obese Patients Without Obstructive Sleep

Apnea Syndrome,î Journal of Internal Medicine, Vol. 253, No. 5 (2003): 536-543.

56 C. Guilleminault, ìClinical Features and Evaluation of Obstructive Sleep Apnea,î eds. M. Kryger, T.

Roth, and W.C. Dement, Principles and Practice of Sleep Medicine, 2nd ed. (Philadelphia: W.B. Saunders

Co., 1994).

57 The driverís height and weight (6 foot 1 inch tall, 380 pounds) meet the clinical criteria for morbid obesity.

58 M.S. Ip, B. Lam, M.M. Ng, W.K. Lam, K.W. Tsang, and K.S. Lam, ìObstructive Sleep Apnea is

Independently Associated with Insulin Resistance,î American Journal of Respiratory and Critical Care

Medicine, Vol. 164, No. 5 (2002): 562-563.

59 Driver perception reaction time ranges from 0.9 to 2.1 seconds. From Thomas A. Dingus, Steven K.

Jahns, Abraham D. Horowitz, and Ronald R Knipling, ìHuman Factors Design Issues for Crash Avoidance

Systems,î eds. Woodrow Barfield and Thomas A. Dingus, Human Factors in ITS (New Jersey: Lawrence

Erlbaum Associates, 1998).
Analysis 36 Highway Accident Report

The driverís history of difficulty maintaining wakefulness, the vanís lack of brake

light illumination, and the gradual drifting of the van off the roadway are consistent with a

driver who has fallen asleep. The Safety Board concludes that the driver fell asleep before

departing the roadway, probably due to an undiagnosed sleep disorder.

Child Care Transportation

Vehicle

In this accident, the children were being transported to school from Tippy Toes, their

child care center, in a 15-passenger van. Because of the severity of this crash, most of the

passengers would have sustained injuries, whether restrained or not, due to the speed at which

the van struck the bridge abutment and the intrusion into the occupant compartment. However,

the injuries would have been less severe for the passengers in the rear of the van had they been

restrained. Because of the intrusion into the front-right passenger area, the front-seat passenger

had little survivable space, regardless of restraint usage. The other fatally injured occupants

were either thrown out of their seating area due to the impact forces or were thrown into the

intruding sidewall as the van impacted the bridge abutment. The two passengers who survived

the accident probably did not sustain fatal injuries because they were farthest from the impact

and intrusion and were quite likely shielded by the other van occupants.

As a result of a 1999 special investigation report,60 which discussed four accidents

involving nonconforming vehicles used for pupil transportation, the Safety Board

recommended that the 50 States and the District of Columbia:

H-99-22

Require that all vehicles carrying more than 10 passengers (buses) and

transporting children to and from school and school-related activities,

including but not limited to, Head Start programs and day care centers,

meet the school bus structural standards or the equivalent as set forth in 49

Code of Federal Regulations Part 571. Enact regulatory measures to

enforce compliance with the revised statutes.

Only 11 States have implemented this recommendation. The Safety Board remains

firmly convinced that the safest way to transport children to or from school or schoolrelated activities is in a vehicle built to school bus standards. From 1993 through 2002,

fatalities to children within school buses averaged just over 5 per year; yet, in that same

timeframe, fatalities to children in 15-passenger vans averaged 57. Further, a School

Transportation News study61 found that the cost per road mile of a 15-passenger school

bus is actually less than the cost of a 15-passenger van, due to the greater life span of a

school bus and reduced maintenance costs.62

60 NTSB/SIR-99/02.

61 School Transportation News, <www.stnonline.com>.
Analysis 37 Highway Accident Report

School buses are built using a design concept known as compartmentalization;63 a

vehicle so constructed would have kept the children within their seating area during the

initial impact with the light pole instead of being thrown from their seating positions

during this initial impact, as predicted by the Safety Boardís accident simulation. The

intrusion into the seating compartment may also have been lessened because of the school

busís greater joint strength. The Safety Board found in its 1999 study64 that school buses

provide better crashworthiness and occupant protection. The study concluded that had the

vehicles involved in these accidents had equivalent occupant crash protection, they

probably would have sustained less damage, and the passengers might have suffered fewer

and less severe injuries. The same can be said for the van and passengers in the Memphis

accident. The Safety Board therefore concludes that had Tippy Toes used a vehicle built to

school bus standards to transport the children to and from school, rather than a 15-

passenger van, the resulting injuries might have been less severe. The Safety Board

continues to urge the 39 States that have not done so, and the District of Columbia, to

include child care centers in their requirement that school buses or buses built to school

bus standards be used for the transportation of children to or from school or school-related

activities and therefore reiterates Safety Recommendation H-99-22.

Restraint Usage

The driver was not restrained, which led to his ejection and fatal injuries. Even if

he had been restrained, his weight and the forces from the crash might have prevented the

restraint system (lap/shoulder belt and airbag) from fully protecting him, resulting in

possible chest injuries. While the driver was not ejected in the Boardís simulation, it

cannot be determined whether the lap/shoulder belt and airbag would have been able to

restrain someone of the accident driverís size, which was at the upper limit for which

restraints are effective.65 Even assuming the lap/shoulder belt could have prevented the

driver from being ejected, he may have suffered chest injuries, most likely due to contact

with the steering wheel.66

Although the Safety Board believes that children should be transported to and

from school or day care in a school bus, we understand that child care centers will

continue to use other vehicles to transport children as school buses and MFSABs are

phased into use. The continued use of non-school bus vehicles makes the use of restraints

62 Maine Bureau of Highway Safety, 15-Passenger Van Training Program (Augusta, Maine: Bureau of

Highway Safety, 2003).

63 In school buses, compartmentalization is used to protect passengers from crash impacts. This is

accomplished by having the seats closely spaced together, with the seat cushions and high seatbacks covered

in an energy-absorbing material. The entire seat structure is designed to absorb energy and to dissipate

through deformation the energy of the crash away from the passenger and into the surrounding

compartment. In addition to using compartmentalization, small school buses are equipped with lap belts

because their size can lead to more passenger movement in a collision.

64 NTSB/SIR-99/02.

65 Federal Motor Vehicle Safety Standard 571.208 only requires that a 50th percentile adult male

dummy be used in the frontal barrier tests of seat belts and airbags.

66 Correspondence with Dr. Jeff Crandall, University of Virginia Center for Applied Biomechanics,

December 15, 2003.
Analysis 38 Highway Accident Report

even more important because the restraints at least offer some measure of protection. In

the Safety Boardís simulations, use of available restraint systems was estimated to reduce

the overall occupant motion and the potential for ejection and injuries from occupant-tooccupant contacts. Further, the simulations showed that, had the children been restrained

in age-appropriate restraints, they probably would have received even less severe injuries.

The predicted injuries of the two children who should have been in booster seats (the 6-

and 8-year-olds) were estimated to be greatly decreased in the simulation when they were

placed in booster seats. This is because the seats provide the proper positioning of the seat

belts on smaller children. (See figure 15 earlier in this report.) An additional benefit of the

booster seats used in the simulation, high-backed boosters with sides, was that they further

contained the occupants within their seating area, reducing potential injuries that would

have been caused by contacting other surfaces within the van.

The 6-year-old who was not placed in a booster seat in the simulation experienced

additional predicted injuries due to improper belt placement. The location of the

attachment points for the lap/shoulder belts and the shoulder attachment caused the

shoulder harness to ride up the torso in the simulation, so that the belt contacted the

occupantís neck. (See figure 15 earlier in this report.) Even though the children in seats 3

and 6 were old enough (both were 10 years old) that they were not recommended to use

booster seats, the shoulder harness of their lap/shoulder belts quite likely would also have

been ill-fitting, crossing the children at the neck due to the location of the upper

anchorages. (See figure 16 earlier in this report.) Ill-fitting lap/shoulder belts can lead to

further injuries, such as increased risk of fractures to the spine and serious abdominal

injuries.67,68 The Safety Board has recommended to manufacturers of 15-passenger vans

that these lap/shoulder belts be adjustable in 15-passenger vans69 because, as currently

configured, these vans locate the shoulder belt upper anchorage high and aft of the

passenger, creating a situation where the belt fits poorly.

The 9-year-old passenger in center seat 7 only had the option of using a lap belt.

The Safety Board has long advocated use of lap/shoulder belts in all seating positions

because they greatly reduce a passengerís risk of injury during a collision. Restrained by

lap belts only, passengers sometimes sustain increased abdominal, head, and neck injuries

as a result of pivoting about the lap belt or due to excessive upper body motion. Both

General Motors Corporation and Ford Motor Company (the current manufacturers of 15-

passenger vans) plan to install lap/shoulder belts at all seating positions by September

2007; General Motorís belts will be adjustable.

Driver Fitness

During the course of the investigation, investigators found other issues associated

with Tippy Toesís child transportation program that contributed to this accident. Despite the

67 C. Gotschall, A. Better, D. Blaus, M. Eichelberger, F. Bents, and M. Warner, ìInjuries to Children

Restrained in 2- and 3-Point Belts,î 42nd Annual Proceedings of the Advancement of Automotive Medicine,

1998.

68 J. Garrett and P. Braunstein, ìThe Seat Belt Syndrome,î Trauma, Vol. 2 (1962): 220.

69 For more information on Safety Recommendation H-03-25, see appendix B.
Analysis 39 Highway Accident Report

TDHS requirements, Tippy Toes had not conducted a background check on or medical

examination of the driver. A background check would have revealed the driverís marijuana

possession arrest, and a medical examination might have identified the driverís marijuana

use and possible sleep apnea. Drug testing also would quite likely have identified the

driverís marijuana use. Although Tippy Toesís employees knew of and thought the owners

were aware of the driverís marijuana use, nothing was done to prevent him from driving

children to and from the child care center. Because Tippy Toes did not forward the driverís

application to the TDHS, as required, the TDHS had no record of this driver being employed

by Tippy Toes or knowledge that the driver had not been given a background check or

medical examination. Reviewing the driverís file would have been one opportunity for the

TDHS to identify this driver and ensure he had been properly screened. Even though TDHS

personnel had another chance to review the driverís file at Tippy Toes, they failed to note the

lack of a background check or medical examination. The Safety Board concludes that

because Tippy Toes did not comply with State law and because the TDHS provided

inadequate oversight of Tippy Toesís operations, the accident driver was able to transport

children, even though he had not had a background check or medical examination.

The accident driver was a known frequent marijuana user and, according to

children and parents, had sometimes smoked marijuana while driving the child care van.

Because marijuana can affect a driverís perception and reaction, riding with this driver

was dangerous. Although the TDHS did not require preemployment drug testing for child

care center drivers at the time of the accident, the agency now requires an initial drug

screening and prohibits those who test positive from driving for a child care center. The

TDHS still does not require random drug tests. The Safety Board concludes that had drug

testing been conducted, the accident driverís drug use would quite likely have been

detected and he may have been prohibited from transporting children. All highway

transportation providers in the United States, from school bus drivers to motorcoach

drivers to truck drivers, must submit to both preemployment and random drug testing.

Child care transportation providers, who transport young children on a daily basis, should

be held to at least the same strict standards as other commercial drivers.

Child Care Transportation Oversight

Public schools currently require that school buses be used to transport children to

or from school and that all drivers hold a commercial driverís license and have a medical

examination. Beginning in 2006, the Head Start program will require its centers to use

vehicles built to school bus standards, restrain children in age-appropriate restraints, and

require drivers to hold a commercial driverís license and have a medical examination.

Children being transported to and from child care centers deserve the same level of

protection as their siblings and neighbors being transported to Head Start or to public

elementary or high schools.

Tippy Toesís owner did not conduct a background check on the driver, did not

inquire about previous traffic or drug convictions, and did not require that the driver

complete a medical examination. Moreover, not only was the owner aware of the driverís

marijuana use, and did nothing to restrict or stop him from driving children to or from

school, she apparently was also aware that two of the attendants believed that one of their
Analysis 40 Highway Accident Report

primary responsibilities was to keep the driver awake. Furthermore, the owner allowed

children to be transported without seat belts or child restraints, thereby violating the State

restraint laws. Had the owner fulfilled any of her responsibilities regarding the transportation

of children, this accident may not have occurred or the consequences may have been less

severe. Therefore, the Safety Board concludes that the complete absence of driver and

transportation operations oversight on the part of Tippy Toesís owner led to this accident.

Following this accident, Tennessee established stricter requirements for child care

center transportation. This new law includes requirements, phased in from 2003 to 2007,

for the use of vehicles built to school bus standards and age-appropriate restraints; for

annual vehicle inspections; for driver background checks, drug tests, and medical

examinations; for commercial driverís licenses; and for vehicle identification. Similarly, a

fatal accident in South Carolina70 prompted that State to pass a law requiring vehicles built

to school bus standards, child restraints, and annual vehicle inspections. However,

Tennessee and South Carolina enacted these stricter laws only after fatal accidents

involving child care transportation. Further, based on the lack of positive response to

Safety Recommendation H-99-22 to require the use of vehicles built to school bus

standards and Safety Recommendation H-96-14 to require the use of booster seats, and on

the lack of existing State laws implementing such safety improvements, the Safety Board

does not believe that significant progress has been made nationally in child care center

transportation safety. The Safety Board concludes that the absence of a comprehensive

safety oversight system for child care transportation places children who are being

transported to and from child care centers at risk.

A comprehensive child care transportation safety program should consist of

vehicle, driver, and operational requirements. Vehicles used for child care transportation

should be built to Federal school bus standards or be multifunction school activity buses

because these vehicles provide greater occupant protection. In addition, as the Safety

Board has advocated and as the simulation showed, children are safest when seated in

properly used, age-appropriate child restraints and, therefore, child care transportation

providers should require children to use such restraints when the vehicle is equipped with

seat belts. Further, vehicles should be maintained and inspected routinely to ensure that

they are in good working order. Although the accident vanís worn brake pad, grooved

brake rotor, and the low rear tire inflation pressures did not contribute to the accident,

these problems are indicative of poor maintenance.

In this accident, major driver deficiencies escaped scrutiny because the driverís

records were not reviewed, the driver never received a background check or a medical

examination, and the driverís drug use was tolerated. Drivers employed by child care

centers should undergo a criminal background check and a physical examination to detect

health or other problems that would impair their driving and endanger the childrenís

safety. Drivers should also be required to submit to preemployment and random drug

testing to detect illicit drug use. Further, an oversight agency should review this driver

70 A 15-passenger van carrying students from a private school to a swimming pool was struck by a

tractor-semitrailer that failed to stop at a red light. One passenger was fatally injured and several others were

seriously injured. The Safety Board did not investigate this accident.
Analysis 41 Highway Accident Report

information, to ensure that child care centers do not overlook driver violations. Finally, so

that passersby can report unsafe drivers, child care vehicles should be labeled with the

names and phone numbers of the child care center and pertinent oversight agency. One

witness said she had seen the Memphis driver sleeping in the vehicle, but had nowhere to

report this issue beyond the child care center. Further, because the driver was reported to

fall asleep at red lights, others may also have noticed his habits, but had no practical

means of notifying anyone of their concerns. Witnesses also stated they believed the child

care operator knew of the driverís drug use but ignored it. Had these witnesses known the

number of the oversight agency, they could have alerted the agency to this unsafe driver.

Based on the circumstances of this and other accidents, the Safety Board believes

that the States and the District of Columbia should implement a comprehensive oversight

program for child care transportation that includes the following elements: use of vehicles

built to school bus standards or of multifunction school activity buses; a regular vehicle

maintenance and inspection program; a requirement that occupants wear age-appropriate

restraints at all times; a requirement that drivers receive a criminal background check and

have a medical examination to determine fitness to drive; preemployment, random,

postaccident, and ìfor causeî drug testing for child care transportation providers and the

prohibition of anyone who tests positive for drugs from transporting children; review by

an oversight agency of periodic driver background checks, medical examinations, and

drug test results; and a requirement that child care vehicles be labeled with the child care

centerís and oversight agencyís names and phone numbers.

To reinforce efforts by the States to establish comprehensive child care safety

oversight programs, the Safety Board proposes that an additional transportation safety

accreditation be established by the National Association for the Education of Young

Children (NAEYC),71 which administers the Nationís largest professionally sponsored,

voluntary accreditation system for all types of early childhood centers and schools. Over

8,000 child care centers hold NAEYC accreditation. NAEYCís accreditation system

currently addresses topics such as curriculum, staffing, child/teacher/parent interaction,

health and safety, nutrition, and program administration. The Safety Board believes that

NAEYC, as part of its accreditation program, should establish a transportation safety

accreditation that requires applicants to implement the same oversight elements that the

Safety Board proposed in its above recommendation to the States.

Another resource available to child care providers as they implement child care

transportation safety oversight programs is the DHHS, which provides Child Care and

Development Funds to States to ìassist low-income families, families receiving temporary

public assistance, and those transitioning from public assistance in obtaining child care so

they can work or attend training/education.î72 In 2003, $4.8 billion in funds were

available. The child care center in this accident received funding in 2002. The DHHS does

not prescribe health and safety requirements; it only requires that child care facilities

71 Over 8,000 child care centers are accredited <www.naeyc.org>, including over 200 federally

sponsored child care centers and over 800 U.S. Department of Defense child care centers

<http://www.nccic.org/pubs/qcare-it/apdx-d.html> and <http://clinton3.nara.gov/WH/Work/031098.html>.

72 <www.acf.dhhs.gov>.
Analysis 42 Highway Accident Report

receiving funds meet State requirements for health and safety. However, the DHHS does

provide resource information on its Web site for child care providers, including links to

NHTSAís recommendations on child restraints. The Safety Board concludes that the DHHS,

which provides child care and development funds to the States, is well-positioned to supply

guidance and information on the safe transportation of children to child care providers. The

Safety Board will ask that the DHHS publish, distribute to local offices, and place on its Web

site, information on the circumstances of this accident and the Safety Boardís

recommendation for a comprehensive child care transportation oversight program, as well as

the Safety Boardís previously published information on 15-passenger van safety.

Barrier Design

As the van departed the roadway, it drove over the top of the guardrail terminal and

became trapped behind the guardrail. Because of the backslope, the guardrail at the

accident location varied in height from 5 inches at the anchored-in-backslope terminal to

26 inches above ground 57 feet beyond the terminal. Yet, because of the backslope, the

guardrail remained level to the pavement surface. This allowed the van to encroach on the

barrier and easily mount it at its anchor point, ride over it, and continue along and behind

the length of the barrier. The use of such a design resulted in a terminal configuration

similar to a turned-down73 terminal, because of the reduction from the full barrier height to

ground level. The Safety Board concludes that had the barrier system in place at the

accident location not tapered into the backslope and had another type of barrier terminal

been used, the van would not have been able to ride over the top of the barrierís

longitudinal guardrail and would probably have been prevented from becoming trapped

behind the guardrail and striking the bridge abutment. While an anchored-in-backslope

design can be effective, it is not a safe design for locations where design hazards exist

along a steep backslope or a horizontal curve, as was true at the accident location. There, the

anchored-in-backslope terminal essentially becomes a flared turned-down design, which is

unsafe and no longer permitted because the turned-down design provides no protection to

errant vehicles. The Safety Board believes that State and District of Columbia Departments

of Transportation should identify guardrails with anchored-in-backslope terminals and

eliminate any that create a situation similar to a turned-down terminal.

The roadside barrier74 extended 160 feet from the bridge abutment. Based on a plot

of the accident site, using the 21-foot clear zone and the 360-foot runout length

recommended by AASHTO for design speeds of 55 mph,75 the barrierís calculated length

of need is 79 feet. As can be seen in figure 18, when the runout length is plotted, it actually

intersects the roadway only 227 feet from the bridge abutment because of the roadwayís

curvature, so that the full 360 feet is not available for errant drivers to recover.

73 A turned-down terminal is a W-beam guardrail that decreases from full height to ground level,

typically over a distance of 25 feet.

74 The barrier comprises the guardrail and the end treatment.

75 AASHTO, Roadside Design Guide, 5-33.
Analysis 43 Highway Accident Report

Because of the horizontal curve before the bridge abutment, the length of need of

the guardrail should be calculated to account for vehicles that leave the roadway tangent to

the curve, as the accident vehicle did. AASHTO states in one of its design examples76 that

when a vehicle leaves the road on the outside of the curve (as in this accident), it generally

follows a tangential path. In such cases, the tangent line from the curve to the clear zone or

outside edge of the hazard should be used instead of the theoretical runout length.

Because of the curvature of the roadway, a vehicle can depart the roadway at a

distance further from the hazard than that predicted by AASHTOís recommended runout

length. When a vehicle ìstraightens outî the curve, it departs the roadway further from the

hazard but still needs to be redirected or provided room to stop. When this occurs, the

vehicle can completely miss the barrier system designed to protect against the hazard, as

was the case in this accident and others. MPD records indicate three fatal (including this

accident) and two property damage accidents at this location between 1997 and 2002 in

which vehicles became trapped behind the guardrail.

The steep grade of the backslope and the wall of the bridge abutment, when

combined with the barrier, created a trap. Once trapped behind the barrier, even had the

driver tried to steer to avoid striking the abutment, he would not have been able to return

to the roadway because the van was trapped between the guardrail and the backslope,

effectively directing the van into the bridge abutment. However, with sufficient stopping

distance, a vehicle could stop before striking the bridge abutment. Thus, the runout length

of the barrier also needs to take into consideration situations in which no clear zone is

available to a driver who gets trapped behind the barrier. In the simulation, the driver

would have had 1.8 seconds to try to bring the vehicle under control from the time he

Figure 18. True runout length on curve.

76 AASHTO, Roadside Design Guide, 5-39.

 Beginning of

 the 360-foot

 runout length

Interstate 240 

(southbound lanes only) 439+00

440+00

441+00

442+00

443+00

 Abutment

227' Point where

 the runout path

 crosses the edge

 of the traveled way

 Upstream from the hazard
Analysis 44 Highway Accident Report

departed the roadway. This is insufficient time to stop a vehicle, and the slope does not

allow the driver to steer away from the barrier.

In the simulation, a vehicle traveling at 65 mph in the left lane and continuing in a

straight path tangent to the curve, instead of following the curvature of the roadway,

would need at least 40 more feet of guardrail with the same end treatment, or 10 feet more

with a different end treatment, to redirect the vehicle onto the roadway. Using AASHTOís

formulas and a runout length of 480 feet (based on the 85th percentile speed of 70 mph)

and plotting the trajectory of a vehicle that leaves the roadway tangential to the curve, the

barrier systemís length of need is 293 feet, exceeding the existing barrierís length by 133

feet, not including the end treatment. (See figure 19.) By extending the barrier, the

likelihood of an errant vehicle impacting the barrier system and being redirected away

from the bridge abutment increases. For a driver trapped behind the barrier, the additional

length would provide the opportunity to stop before colliding with the bridge abutment.

The Safety Board concludes that given the roadway curvature and the lack of a clear

zone, the barrier at the accident site was not long enough to prevent a vehicle that departed

the roadway from going behind the barrier or to allow an errant vehicle to recover before

striking the bridge abutment. AASHTOís Roadside Design Guide does not specifically

address these types of situations or direct the highway designer to examine the need for

longer runout lengths if the conditions could contribute to a vehicle becoming trapped

behind the barrier or if the roadway curves. The Safety Board believes that AASHTO should

modify the guidance contained in the Roadside Design Guide to clearly provide designers

with information on the design of roadway barrier systems in situations where the roadway

curves or where the terrain, hazards, and barrier system could trap an errant vehicle behind

the barrier system. The Safety Board will ask AASHTO to inform its members of the

circumstances of this accident and of the importance of considering roadway curvature and

terrain configurations in the design of barrier systems.

Figure 19. Length of need based on speed and roadway curvature.

439+00

440+00

441+00

442+00

443+00

 Abutment

160'

133'

Additional length required for 

the length of need

(does not include the terminal end) Length of existing barrier system 

(upstream from hazard)

480-foot runout length

based on a 70-mph

design speed

Interstate 240 

(southbound lanes only) 
45 Highway Accident Report

Conclusions

Findings

1. Neither the weather nor the mechanical condition of the van contributed to the

accident, and the emergency response was timely and appropriate.

2. The driver consumed marijuana on the morning of the accident and was under the

influence of the drug at the time of the crash.

3. The driver fell asleep before departing the roadway, probably due to an undiagnosed

sleep disorder.

4. Had Tippy Toes Learning Academy used a vehicle built to school bus standards to

transport the children to and from school, rather than a 15-passenger van, the injuries

resulting from this accident might have been less severe.

5. Because Tippy Toes Learning Academy did not comply with State law and because

the Tennessee Department of Human Services provided inadequate oversight of

Tippy Toes Learning Academyís operations, the accident driver was able to transport

children, even though he had not had a background check or medical examination.

6. Had drug testing been conducted, the accident driverís drug use would quite likely

have been detected, and he may have been prohibited from transporting children.

7. The complete absence of driver and transportation operations oversight on the part of

Tippy Toes Learning Academyís owner led to this accident.

8. The absence of a comprehensive safety oversight system for child care transportation

places children who are being transported to and from child care centers at risk.

9. The U.S. Department of Health and Human Services, which provides child care and

development funds to the States, is well-positioned to supply guidance and

information on the safe transportation of children to child care providers.

10. Had the barrier system in place at the accident location not tapered into the backslope

and had another type of barrier terminal been used, the van would not have been able

to ride over the top of the barrierís longitudinal guardrail and would probably have

been prevented from becoming trapped behind the guardrail and striking the bridge

abutment.

11. Given the roadway curvature and the lack of a clear zone, the barrier at the accident

site was not long enough to prevent a vehicle that departed the roadway from going

behind the barrier or to allow an errant vehicle to recover before striking the bridge

abutment. 
Conclusions 46 Highway Accident Report

Probable Cause

The Safety Board determines that the probable cause of this accident was the

absence of oversight by Tippy Toes Learning Academy and the driverís inability to

maintain control of his vehicle because he fell asleep, quite likely due to an undiagnosed

sleep disorder; the driverís marijuana use may also have had a role in the accident.

Contributing to the accident was the Tennessee Department of Human Servicesí lack of

oversight of child care transportation. Contributing to the severity of the injuries were the

use of a 15-passenger van to transport pupils, the nonuse of appropriate restraints, and the

design of the roadside barrier system.
47 Highway Accident Report

Recommendations

New Recommendations

As a result of its investigation of the April 4, 2002, 15-passenger child care van

accident, the National Transportation Safety Board makes the following recommendations:

To the State and District of Columbia Child Care Transportation Oversight Agencies:

Implement an oversight program for child care transportation that includes

the following elements:

ï Use of vehicles built to school bus standards or of multifunction school activity

buses; (H-04-8)

ï A regular vehicle maintenance and inspection program; (H-04-9)

ï A requirement that occupants wear age-appropriate restraints at all times;

(H-04-10)

ï A requirement that drivers receive a criminal background check and have a

medical examination to determine fitness to drive; (H-04-11)

ï Preemployment, random, postaccident, and ìfor causeî drug testing for all

child care transportation providers and the prohibition of anyone who tests

positive for drugs from transporting children; (H-04-12)

ï Review by an oversight agency of periodic driver background checks, medical

examinations, and drug test results; (H-04-13) and

ï A requirement that child care vehicles be labeled with the child care centerís

and oversight agencyís names and phone numbers. (H-04-14)

To the State and District of Columbia Departments of Transportation:

Identify guardrails with anchored-in-backslope terminals and eliminate any

that create a situation similar to a turned-down terminal. (H-04-15)
Recommendations 48 Highway Accident Report

To the National Association for the Education of Young Children:

As part of your accreditation program, establish a transportation safety

accreditation that requires applicants to implement the following elements:

(H-04-16)

ï Use of vehicles built to school bus standards or of multifunction school activity

buses;

ï A regular vehicle maintenance and inspection program;

ï A requirement that occupants wear age-appropriate restraints at all times;

ï A requirement that drivers receive a criminal background check and have a

medical examination to determine fitness to drive;

ï Preemployment, random, postaccident, and ìfor causeî drug testing for all

child care transportation providers and the prohibition of anyone who tests

positive for drugs from transporting children;

ï Review by an oversight agency of periodic driver background checks, medical

examinations, and drug test results; and

ï A requirement that child care vehicles be labeled with the child care centerís

and oversight agencyís names and phone numbers.

To the American Association of State Highway and Transportation Officials:

Modify the guidance contained in the Roadside Design Guide to clearly

provide designers with information on the design of roadway barrier

systems in situations where the roadway curves or where the terrain,

hazards, and barrier system could trap an errant vehicle behind the barrier

system. (H-04-17)

Previously Issued Recommendation Reiterated in This Report

The National Transportation Safety Board reiterates the following recommendation:

To the States (except Alaska, Delaware, Indiana, Massachusetts, Nebraska, New

Jersey, New York, Pennsylvania, South Carolina, Utah, and Vermont) and the District of

Columbia:

Require that all vehicles carrying more than 10 passengers (buses) and

transporting children to and from school and school-related activities,

including but not limited to, Head Start programs and day care centers,

meet the school bus structural standards or the equivalent as set forth in 49

Code of Federal Regulations Part 571. Enact regulatory measures to

enforce compliance with the revised statutes. (H-99-22)
Recommendations 49 Highway Accident Report

Previously Issued Recommendation Classified in This Report

For the State of Vermont, the previously issued recommendation H-99-22 cited

above is classified in this report:

Safety Recommendation H-99-22 (previously classified ìOpenóAcceptable

Responseî) is classified ìClosedóAcceptable Action.î

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: April 7, 2004

51 Highway Accident Report

Appendix A

Investigation and Public Hearing

The National Transportation Safety Board was notified of the Memphis,

Tennessee, accident on April 4, 2002. An investigative team was dispatched, including

members from the Washington, D.C.; Arlington, Texas; Denver, Colorado; Gardena,

California; and Parsippany, New Jersey, offices. Groups were established to investigate

human performance; motor carrier operations; and highway, vehicle, and survival factors.

Parties to the investigation were the Tennessee Department of Human Services,

Tennessee Department of Transportation, and the Memphis Police Department.

No public hearing was held.
52 Highway Accident Report

Appendix B

Previous Recommendations

For a summary of State compliance with the Safety Board recommendations

discussed below, see table B-1 at the end of this appendix.

Restraint Usage

On September 20, 1996, the Safety Board adopted a safety study on The

Performance and Use of Child Restraint Systems, Seat Belts, and Air Bags for Children in

Passenger Vehicles.1

 As a result of that study, the Safety Board issued the following safety

recommendations to the governors and legislative leaders of the 50 States and U.S.

Territories and to the mayor and chairman of the council of the District of Columbia:

H-96-13 through -16

Emphasize the importance of transporting children in the back seat of

passenger vehicles through educational materials disseminated by the

State. Consider setting aside one-tenth of 1 percent from all motor vehicle

insurance premiums for policies written to establish a highway safety fund

to be used for this and other safety efforts. (H-96-13)

Review existing laws and enact legislation, if needed, that would:

Ensure that children up to 8 years old are required by the Stateís mandatory

child restraint use law to use child restraint systems and booster seats.

(H-96-14)2

Eliminate exemptions for children to substitute seat belts in place of child

restraint systems. (H-96-15)

Require children 8 years or older to use seat belts in all vehicle seating

positions. (H-96-16)

The Safety Board classified Safety Recommendation H-96-13 ìClosedó

Acceptable Actionî for all of the States and the District of Columbia.

H-96-14 is on the Safety Boardís Most Wanted List of Safety Improvements.

Eleven States complied with H-96-14; 17 States and the District of Columbia with H-96-

15; and 45 States and the District of Columbia with H-96-16.

1 NTSB/SS-96/01.

2 This recommendation is on the Safety Boardís ìMost Wantedî list. For further information, see NTSB

Most Wanted Transportation Safety Improvements 2004 <www.ntsb.gov/Recs/mostwanted/index.htm>.
Appendix B 53 Highway Accident Report

The Safety Boardís most recent report on 15-passenger van safety3 also addressed

restraint issues. As a result of this investigation, the Safety Board recommended that the

National Highway Traffic Safety Administration (NHTSA):

H-03-15

Include 12- and 15-passenger vans in your upcoming rulemaking that will

require lap/shoulder belts at all center seats.

NHTSA responded on December 2, 2003, that it had issued a Notice of Proposed

Rulemaking on August 6, 2003, that would require lap/shoulder belts at all front-facing

seating positions other than front-center seats. Pending completion of the final rule, for

which the Safety Board has encouraged the inclusion of 12- and 15-passenger vans, the

Safety Board has classified Safety Recommendation H-03-15 ìOpenóAcceptable

Responseî on April 15, 2004.

The Safety Board also recommended that Ford Motor Company and General

Motors Corporation,4

 the manufacturers of 15-passenger vans:

H-03-25

Voluntarily install lap/shoulder belts at all center seating positions in 12-

and 15-passenger vans and make all lap/shoulder belts in outboard and

center seating positions adjustable by model year 2006.

At the time of publication, the Safety Board was evaluating Ford Motor

Companyís and General Motors Corporationís responses, which were received

November 3, 2003, and March 26, 2004, respectively.

School Bus Occupant Protection Standards

In 1998 and 1999, the Safety Board investigated four accidents involving vehicles

used to transport children to or from school that were not built to school bus occupant

protection standards. Three of these accidents involved 15-passenger vans. The Safety

Board adopted a report and issued recommendations in 1999.5

 Most of the recommendations

3 NTSB/HAR-03/03.

4 Dodge no longer manufactures 15-passenger vans; the last model year was 2002.

5 NTSB/SIR-99/02.
Appendix B 54 Highway Accident Report

pertained to the transportation of children to or from school or school-related activities,

including day care and Head Start. The Safety Board recommended that the 50 States and

the District of Columbia:

H-99-22

Require that all vehicles carrying more than 10 passengers (buses) and

transporting children to and from school and school-related activities,

including but not limited to, Head Start programs and day care centers,

meet the school bus structural standards or the equivalent as set forth in 49

Code of Federal Regulations Part 571. Enact regulatory measures to

enforce compliance with the revised statutes.

The Safety Board classified Safety Recommendation H-99-22 ìOpenó

Unacceptable Responseî for Tennessee, because, although being phased out for day care

transportation, 15-passenger vans can still be used for school transportation. Only 10

States complied with this recommendation: Alaska, Delaware, Indiana, Massachusetts,

Nebraska, New Jersey, New York, Pennsylvania, South Carolina, and Utah. Consequently,

the Safety Board classified Safety Recommendation H-99-22 ìClosedóAcceptable

Actionî for those States. Information obtained during this accident investigation revealed

that Vermont also complied with this recommendation and therefore, for Vermont, the

Safety Board has classified Safety Recommendation H-99-22 ìClosedóAcceptable

Action.î
Appendix B 55 Highway Accident Report

Table 3. State compliance with safety recommendations.

H-96-13 H-96-14 H-96-15 H-96-16 H-99-22

Alabama C

Alaska C C C

Arizona C C

Arkansas C P P C

California C P P C

Colorado C P P C

Connecticut C C

Delaware C C C C C

District of 

Columbia

C C C C

Florida C C C

Georgia C C

Hawaii C C

Idaho C C

Illinois C C C C

Indiana C C C C C

Iowa C

Kansas C C P

Kentucky C C C

Louisiana C P P C

Maine C C C C

Maryland C P C C

Massachusetts C C C

Michigan C C C P

Minnesota C

Mississippi C P

Missouri C C P

Montana C P P C

Table B-1.
Appendix B 56 Highway Accident Report

H-96-13 H-96-14 H-96-15 H-96-16 H-99-22

Nebraska C P P C C

Nevada C P C C P

New Hampshire C P C C P

New Jersey C C C C C

New Mexico C C P

New York C C C

North Carolina C C C

North Dakota C C

Ohio C P

Oklahoma C C P

Oregon C P P C

Pennsylvania C C C C C

Rhode Island C C C C P

South Carolina C P P C C

South Dakota C C

Tennessee C C C C

Texas C C

Utah C C C

Vermont C C C C C

Virginia C P P C

Washington C P P C P

West Virginia C C

Wisconsin C C

Wyoming C C C C

C - complies with the recommendation.

P - partially complies with the recommendation.