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 National Transportation Safety Board Washington, DC 20594 

 Highway Accident Brief

Accident Number: HWY-06-MH-013 

Accident Type: Rear-end chain-reaction collision 

Location: State Route 121, near Lake Butler, Florida 

Date and Time: January 25, 2006, 3:25 p.m. eastern standard time 

Vehicles: 1996 Thomas Built school bus 

1993 Pontiac Bonneville sedan 

2004 Freightliner truck tractor and 1998 Wabash box trailer 

Owners/Operators: Union County, Florida, School District 

Private owner 

Crete Carrier Corporation 

Fatalities/Injuries: 7 fatalities 

5 serious injuries 

6 minor injuries 

Accident Description 

About 2:40 p.m. on Wednesday, January 25, 2006, a 31-year-old truck driver, operating a 

75,360-pound 2004 Freightliner truck tractor and 1998 Wabash box trailer combination unit 

(Freightliner), departed High Springs, Florida, on an 85-mile trip to a company warehouse in 

Jacksonville, Florida. The driver was transporting a load of bottled water. Meanwhile, about 

3:05 p.m., a 48-year-old school bus driver began her afternoon route in a 1996 Thomas Built 

school bus, Union County bus no. 13. 

The northbound school bus was stopped on State Route (SR) 121 at bus stop no. 10, near 

75th SW Terrace, to discharge two students. A 1993 Pontiac Bonneville—occupied by a 

15-year-old driver and six passengers, ages 20 months to 15 years—was stopped behind the 

school bus. As the school bus was beginning to proceed, the Freightliner collided with the rear of 

the Pontiac and the bus. Police estimated the speed of the Freightliner to be 62 mph. 

The Freightliner and the Pontiac continued forward from the impact area, 

departing the travel lanes to the right. The Freightliner then traveled 260 feet and 

collided with a 21-inch-diameter pine tree. The Pontiac was pushed 272 feet to its final 

position, where it was destroyed in a postcrash fire. The school bus was pushed a distance of 328 

feet and came to rest on the right side of the road. Both the Freightliner and the school bus 

sustained extensive impact damage. 

All seven occupants of the Pontiac were killed. Three of the nine students on the school 

bus were ejected from the rear of the vehicle and landed on highway pavement, seriously injured. 

One other student sustained serious injuries and was extricated from the bus by firefighters. The 

school bus driver, who was wearing a lap shoulder belt, also sustained serious injuries. Five 
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students and the truck driver received minor injuries. The students who had been discharged 

from the bus just before the accident were not injured. Figure 1 shows the seating chart for the 

school bus, and table 1 provides injury information. 

Figure 1. Seating chart, Union County school bus. 
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Table 1. Injuries. 

InjuryA School bus 

driver 

School bus 

passengers 

Pontiac 

occupants 

Truck 

driver 

Total 

Fatal 0 0 7 0 7 

Serious 1 4 0 0 5 

Minor 0 5 0 1 6 

None 0 0 0 0 0 

Total 1 9 7 1 18 

A

Title 49 Code of Federal Regulations (CFR) 830.2 defines fatal injury as any injury that results 

in death within 30 days of the accident. It defines serious injury as any injury that requires 

hospitalization for more than 48 hours, commencing within 7 days of the date of injury; results in 

a fracture of any bone (except simple fractures of the fingers, toes, or nose); causes severe 

hemorrhages, or nerve, muscle, or tendon damage; involves any internal organ; or involves 

second- or third-degree burns, or any burns affecting more than 5 percent of the body surface.

Highway 

The accident occurred on SR 121 at milepost 5.4. The Florida Department of 

Transportation (FDOT) classifies SR 121 as a rural minor arterial roadway.1

 According to 

FDOT, the average daily traffic on this roadway in 2004 in the vicinity of the accident was 6,100 

vehicles, with buses accounting for 1 percent and trucks accounting for 22 percent of the total 

vehicular traffic. 

At the accident location, SR 121 is a two-lane undivided asphalt roadway running 

north–south. The paved area consists of two 12-foot-wide main travel lanes, marked by 

solid 6-inch white lines, with a 5-foot-wide shoulder on either side. The paved shoulders 

border 3-foot-wide grass areas. A 6-inch yellow dashed centerline separates the northbound and 

southbound lanes. The speed limit was 60 mph, and speed limit signs were located 2.7 miles 

prior to the accident scene.2

 Figure 2 presents a view of SR 121 northbound, 375 feet prior to the 

accident location. 

 1

 American Association of State Highway and Transportation Officials, A Policy on Geometric Design of 

Highways and Streets, fifth edition (Washington, DC: AASHTO, 2004) 9. AASHTO classifies a rural minor 

arterial roadway as follows: “The rural minor arterial road system, in conjunction with the rural principal arterial 

system, forms a network with the following service characteristics: 1. Linkage of cities, larger towns, and other 

traffic generators (such as major resort areas) that are capable of attracting travel over similarly long distances. 

2. Integrated interstate and intercounty service. 3. Internal spacing consistent with population density, so that all 

developed areas of the state are within reasonable distances of arterial highways. 4. Corridor movements consistent 

with items (1) through (3) with trip lengths and travel densities greater than those predominantly served by rural 

collector or local systems.” 2

 A speed study conducted by Safety Board investigators on January 30, 2006, from 3:00–4:00 p.m., in the 

northbound lanes of SR 121, showed the 85th percentile speed as 65 mph. 
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Figure 2. SR 121 approaching accident location. 

The 2003 Manual on Uniform Traffic Control Devices (MUTCD) recommends that 

School Bus Stop Ahead signs be installed in advance of school bus stops where the bus is not 

visible to road users for a distance of 500 feet.3

 FDOT provides similar guidance.4 No school bus 

signs were located in the vicinity of the accident. The Safety Board conducted a sight distance 

test on January 31 and February 1, 2006, assisted by the Florida Highway Patrol, which showed 

that the school bus was visible for a distance of 3,087 feet, far above the recommended 500 feet. 

The alternating red warning lights on the rear of the school bus were visible at 1,382 feet. A 

regulatory sign stating All Traffic Both Directions STOP While School Buses Load or Unload

was located about 4 miles in advance of the accident site. 

Vehicles 

School Bus 

The accident bus was a 65-passenger school bus manufactured in 1996 by Thomas Built 

Buses, Inc. The bus weighed 17,250 pounds and had a body length of 417.9 inches. 

The bus sustained the majority of damage at the rear end, where it was struck by the 

Freightliner. The rear of the bus was pushed inward just left of center, which affected the entire 

rear surface area of the bus, to just below roof level. (See figure 3.) The maximum point of 

 3

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

Devices for Streets and Highways, Part 7, Traffic Controls for School Areas (Washington, DC: FHWA, 2003) 7B-3. 4

 Florida Department of Transportation, Design Standards, School Signs, and Markings, Sheet No. 4 of 6, 

Index No. 17344 (Tallahassee, FL: FDOT, 2006). 
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inward intrusion was about 5 feet. The entire bus body was deformed from the rear-end damage, 

and the driver’s seat was sheared off its pedestal mounting. 

Figure 3. Accident school bus. 

The tires on the bus met recommended manufacturer specifications and were in good 

condition. The steering and the suspension systems appeared to be normal. The brake on the left 

front axle was found to be out of adjustment and would have resulted in the bus being out of 

service according to the Commercial Vehicle Safety Alliance North American Standard Out-ofService Criteria. However, the bus was nearly stopped at the time of the accident, and the 

braking system was not causal to the accident. 

Statements from the bus driver, passengers, and a witness driving in the opposite 

direction indicated that the bus warning lights and strobe light were activated while the bus was 

stopped and discharging passengers. Statements from the bus driver and passengers also 

indicated that, at the time of impact, the school bus door was closed, the warning lights were 

turned off, and the bus was beginning to move forward. The Safety Board laboratory 

examination of the lights revealed that none of the filaments contained hot stretching damage.5

 5

 The Safety Board examined the warning lights in the dash; the top-rear, bottom-rear, top-front, and 

bottom-front stop sign light bulbs; and the left-rear, middle-rear, right-rear, left-side, and right-side clearance lights. 
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Passenger Car 

The passenger car involved in the accident was a 1993 Pontiac Bonneville. The sedan 

had a precrash curb weight of 3,355 pounds, a length of 200.9 inches, a width of 73.7 inches, and 

an overall height of 55.6 inches. 

The vehicle was extensively damaged by the impact of the Freightliner and the postcrash 

fire, which consumed most of its nonmetal components. (See figure 4.) The Florida State Fire 

Marshal determined that the origin of the fire was the fuel tank located at the rear of the vehicle; 

the tank was found to have been breached as a result of the crash and to have come into contact 

with the pavement, introducing an ignition source. The fuel tank had a small tear from being 

ground into the pavement. 

Figure 4. Remains of accident passenger car. 

Tractor-Trailer Combination Unit 

The accident truck tractor was a 2004 Freightliner, and the trailer was a 1998 Wabash 

box trailer 53 feet long, 13.5 feet tall, and 8.5 feet wide. The total weight of the truck 

tractor-trailer combination unit was estimated to be 75,360 pounds. 

The tractor and the front of the trailer, shown in figures 5 and 6, sustained the majority of 

the damage. The cab portion of the tractor was completely detached and separated from the 

tractor chassis. 
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Figure 5. Cab portion of accident tractor. 

Figure 6. Front of accident box trailer. 
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The tires on the tractor were slightly narrower than the width recommended by the tractor 

specifications.6

 However, this discrepancy would not have affected the rolling radius or vehicle 

handling. Damage to the steering and suspension systems appeared to be a direct result of the 

accident. The brakes of the tractor and trailer were found to be in adjustment and in good 

condition. 

The tractor was equipped with a Detroit Diesel model DDEC-V electronic engine control 

module (ECM). Although the ECM data were analyzed, no precrash data associated with the 

accident were identified. This ECM was not designed or intended to function as an event data 

recording device. 

Motor Carriers 

Union County School District 

The Union County School District—which covers about 80 square miles with 21 bus 

routes—has one elementary school, one middle school, and one high school. The school bus fleet 

consisted of twenty 65-passenger buses, three 71-passenger buses, one 47-passenger bus, and 

two special needs buses. At the time of the accident, the school district employed 19 full-time 

drivers, 4 substitute drivers, 2 full-time mechanics, and a transportation specialist who also did 

mechanical work. 

Crete Carrier Corporation 

Operating since 1966, Crete Carrier Corporation is an interstate, authorized for-hire carrier 

of general freight, building materials, and produce.7

 At the time of the accident, Crete employed 

4,823 company drivers and 391 owner/operators. Of the company drivers, 202 are team drivers; 

and of the owner/operators, 44 are team drivers. Sixty-eight of the Crete drivers operate in 

intrastate commerce only. Crete’s fleet includes 5,170 truck tractors and 12,482 semitrailers. In 

2005, Crete’s fleet traveled a total of 635.8 million miles. 

Roadside inspections for the 12 months prior to the accident indicate that 3,808 Crete 

vehicles were inspected, and 447 were placed out of service (12 percent). Additionally, of 

6,157 driver inspections, 145 drivers were placed out of service (2 percent).8

 The accident rate9

for Crete was 0.64 per million miles traveled. 

A postcrash compliance review conducted by the Federal Motor Carrier Safety 

Administration (FMCSA) on March 15, 2006, resulted in a proposed conditional rating, but 

because of a consent agreement, the rating remained “satisfactory.” In response to the 

compliance review, Crete developed a safety management plan, signed a consent agreement with 

 6

 The 275/80R22.5-size tires on the tractor were just under 1 inch narrower than the 295/80R22.5-size tires 

recommended in the tractor specifications. 7

 Dba Crete Carrier Corp Shaffer Trucking HTL Truck Line. 

8

 The national out-of-service rate for fiscal year (FY) 2006 was 7.0 percent for truck drivers and 23.7 percent 

for trucks. In FY 2007, the national out-of-service rate was 6.8 percent for truck drivers and 22.4 percent for trucks. 

See <http://www.fmcsa.dot.gov/facts-research/art-safety-progress-report.htm>. 9

 Accident rate is defined as the number of recordable accidents per million miles traveled. The FMCSA has 

determined that motor carriers with an accident rate of 1.5 or greater are deficient in the accident area of the 

compliance review rating process. 
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the FMCSA to settle all assessed fines, and agreed to three progress reviews over the following 

18 months.10 The most recent compliance review, and the last of the three required progress 

reviews, was conducted on May 25, 2007, and Crete received a satisfactory rating. The last time 

Crete had been subjected to an FMCSA compliance review was 10 years prior to the accident, on 

December 7, 1995. 

Driver Information 

Bus Driver 

The 48-year-old school bus driver possessed a valid Florida class B commercial driver’s 

license (CDL) with no restrictions and a passenger bus endorsement. The license was originally 

issued on September 26, 1997. The driver had no record of traffic violations since January 2000. 

Automobile Driver 

The driver of the Pontiac Bonneville was a 15-year-old high school student. She held a 

valid Florida class E learner’s permit and had no record of traffic violations. However, at the 

time of the accident, she was operating without a qualified driver in violation of Florida law. 

Truck Driver 

The 31-year-old truck driver possessed a valid Florida class A CDL, originally issued in 

December 2003, with no restrictions and a hazardous materials endorsement. His Florida driving 

record showed no traffic violations since October 2001. He had 2 years of truck driving 

experience, including 10 months driving with Crete (since March 2005) as a company driver. 

The driver had a valid medical certificate and was in good general health. No ethyl alcohol or 

drugs were detected in the toxicological sample obtained from the truck driver by the Florida 

Department of Law Enforcement. 

Data from the DDEC indicated that—in the 72 hours prior to the accident—the truck had 

been driven a total of 24 hours 57 minutes and had idled for 8 hours 38 minutes. The truck 

driver, through his lawyer, declined to be interviewed by Safety Board investigators. The 

following summary of his work–rest history is based on the truck driver’s statement taken on 

May 7, 2008.11 Qualcomm12 data supported his statement. He had been driving a regular route 

between Jacksonville and High Springs, Florida, for about 2 months prior to the accident. A 

round trip took about 5 hours—2 hours from Jacksonville to High Springs, 30–60 minutes 

loading or switching trailers, and 2 hours for the return trip. 

On Saturday, January 21, the truck driver began driving at 1:27 p.m. and continued until 

6:30 p.m. The following day, he worked from 12:42 p.m. until 6:00 p.m. He was off duty until 

 10 If improvements were not achieved during the 18-month period, the safety rating would have reverted to 

conditional. 11 State of Florida v. Alvin E. Wilkerson, Examination Under Oath Taken by Plaintiff, May 7, 2008, at Alachua 

County State Attorney’s Office, case no. 63-2006-CF-000204-A. 12 The Qualcomm Qtracs system uses a transmitter/receiver that allows objects to be continually tracked 

through global positioning satellites. The system identifies the location of each truck every hour, as well as the 

corresponding time and date and whether the truck engine is running. 
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6:29 a.m. on Monday, January 23, and worked until 8:23 p.m. that evening, a total of 14 hours. 

On Tuesday, January 24, he began driving at 5:19 a.m., making two round trips from 

Jacksonville to High Springs and a half trip back to High Springs shortly after midnight on 

January 25. The driver said he slept in the sleeper berth for a couple of hours while the truck was 

being loaded. Then he made the return trip to Jacksonville. The driver said he “rested his head 

across the steering wheel” for an hour or two when he returned to Jacksonville. He made another 

trip to High Springs on the morning of January 25 and was on his way back to Jacksonville when 

the accident occurred, at 3:25 p.m. (See figure 7.) Prior to the accident, the last period of time the 

driver had to obtain significant sleep was when he was off duty from 8:23 p.m. on January 23 

until 5:19 a.m. on January 24. With the exception of a 2-hour sleep period in the early morning 

of January 25 and 1–2 hours of rest about 7:00 a.m., the truck driver was awake for about 30 

hours, and it had been 34 hours since his last substantial off-duty period. The DDEC showed that 

the truck had been driven a total of 13.5 hours and idled for 4 hours 13 minutes during this 

period. 

Dates

1/21

1/22

1/23

1/24

1/25 Accident occurs at 3:25 p.m.

on-duty off-duty napping or resting

12am123456789101112pm1234567891011

Figure 7. Duty status of Freightliner driver, January 21–25, 2006. 

The reduced quantity and quality of sleep would have made the truck driver susceptible 

to fatigue and impaired performance. Research has shown that—in spite of individual 

variations—a specific amount of uninterrupted sleep is necessary for each 24-hour period, 

usually about 8 hours, and subsequent alertness will be compromised without that sleep.13

Additionally, sleeping less than 4 consolidated hours can impair performance for tasks that 

require vigilance.14 Fatigue impairs information processing and reaction times, increasing the 

probability of errors.15

Because of the body’s natural circadian rhythms, there are two periods of maximal 

sleepiness in a 24-hour day—one roughly between 3:00–5:00 a.m. and a second, less pronounced 

 13 (a) Mary A. Carskadon and William C. Dement, “Normal Human Sleep: An Overview,” Principles 

and Practice of Sleep Medicine, second edition, eds., M. Kryger, T. Roth, and W. C. Dement (Philadelphia, 

PA: W. B. Sanders Company, 1994) 16–26. (b) Thomas Roth, Timothy A. Roehrs, Mary A. Carskadon, and 

William C. Dement, “Daytime Sleepiness and Alertness,” Principles and Practice of Sleep Medicine. 14 P. Naitoh, “Minimal Sleep to Maintain Performance: the Search for Sleep Quantum in Sustained Operations,” 

Why We Nap: Evolution, Chronobiology and Functions of Polyphasic and Ultrashort Sleep, ed., C. Stampi (Boston, 

MA: Birkhauser, 1992) 199–216. 15 (a) D. F. Dinges, “The Nature of Sleepiness: Causes, Context, and Consequences,” Perspectives in 

Behavioral Medicine: Eating, Sleeping, and Sex, eds., A. Stunkard and A. Baum (Hillsdale, NJ: Lawrence 

Erlbaum, 1989) 147–179. (b) D. F. Dinges, “Probing the Limits of Functional Capability: the Effects of Sleep 

Loss on Short-Duration Tasks,” Sleep, Arousal and Performance: Problems and Promises, eds., R. J. Broughton 

and R. Ogilvie (Boston, MA: Birkauser-Boston, Inc., 1992). 
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period, from 3:00–5:00 p.m. The Lake Butler accident occurred about 3:25 p.m., a time when the 

driver may have been predisposed to sleepiness, particularly after being awake for approximately 

34 hours with short periods of time as the only opportunities for sleep. 

FDOT determined that the accident truck driver was classified as an interstate operator 

because he had traveled outside the State of Florida to Georgia in November 2005 and to 

Arizona, California, Mississippi, Nevada, South Carolina, Tennessee, Texas, and Utah in 

October 2005. Because the driver had operated in interstate commerce, he was considered to be 

an interstate operator and subject to the Federal hours-of-service regulations. 

As codified in 49 CFR 395, Federal hours-of-service regulations permit a person to drive 

for 11 hours following 10 consecutive hours off duty. Additionally, a person cannot drive beyond 

the 14th hour after coming on duty following 10 consecutive hours off duty. The 60/70-hour rule 

states that a person cannot drive after having been on duty 60 hours in 7 consecutive days or 

70 hours in 8 consecutive days. The accident driver was in violation of the regulations for 

driving and being on duty without receiving 10 consecutive hours off duty and also in violation 

of the 60/70-hour rule for having been on duty more than the permitted time. 

The U.S. Department of Transportation defines a driver as operating in interstate or 

intrastate commerce based on the particular load origination and destination at the time of 

shipment. Consequently, the FMCSA classified this driver and this shipment as an intrastate 

operation not subject to Federal hours-of-service regulations. 

At the time of the accident, Florida permitted a driver in intrastate commerce to drive 

for 15 hours in a 24-hour period, following 8 hours off duty, if the driving was done within a 

200-mile radius. Additionally, a driver could not drive over 72 hours in 7 days or 84 hours in 8 

days. The Qualcomm data for the Freightliner indicate a loss of signal for about 9 hours, from 

8:23 p.m. on January 23 until 5:19 a.m. on January 24. The driver was on duty from 5:19 a.m. 

that morning until the accident occurred at 3:25 p.m. the following day, January 25, 

approximately 34 hours. The driver did not receive an additional 8-hour off-duty period within 

24 hours, placing him in violation of Florida regulations. 

Florida revised its hours-of-service regulations for intrastate commerce on October 1, 

2006. The maximum 24-hour driving time was reduced to 12 hours following 10 consecutive 

hours off duty and no more than 70 hours in 7 days or 80 hours in 8 days. The accident driver 

would not have been in compliance with these revised State regulations. 

In total, the accident driver made three and a half round trips between Jacksonville and 

High Springs, Florida, from January 24–25. Had he not been involved in the accident, he would 

have completed four round trips. Even with only three round trips between the two locations, it 

would have been very difficult to remain in compliance with the hours-of-service regulations. 

Qualcomm communication data show that the driver was asked to make three round trips on this 

route or at least two and a half runs, thus pressuring the driver to the outer limits of the State 

regulation. Furthermore, the Qualcomm data show the location of the truck and should have 

alerted Crete that the driver was making more trips than would have been allowable. 
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Probable Cause 

The National Transportation Safety Board determines that the probable cause of this 

accident was the failure of the truck driver to maintain alertness due to fatigue from obtaining 

inadequate rest. Contributing to the accident was the failure of Crete Carrier Corporation to 

exercise proper oversight of the driver’s hours of service. 

Adopted: August 22, 2008