The loss of lives and property resulting from commercial motor vehicle accidents has been a focus of public concern for several years. In 2006, about 5,300 people died as a result of crashes involving large commercial trucks or buses, and about 126,000 more were injured. A recent study performed by DOT showed that a significant number of commercial driver crashes were due to a physical impairment of the driver. Specifically, DOT found that about 12 percent of the crashes where the crash cause could be identified were due to drivers falling asleep, being disabled by a heart attack or seizure, or other physical impairments. The Federal Motor Carrier Safety Administration (FMCSA) within DOT shoulders the primary federal responsibility for reducing crashes, injuries, and fatalities involving large trucks and buses. FMCSA's primary means of preventing these crashes is to develop and enforce regulations to help ensure that drivers and motor carriers are operating in a safe manner. FMCSA's regulations, among other things, require that drivers of commercial motor vehicles are 21 years old, can read and speak the English language, have a current and valid commercial motor vehicle operator's license, have successfully completed a driver's road test, and are physically qualified to drive. As part of these regulations, FMCSA established standards for the physical qualifications of commercial drivers, including the requirement of a medical certification from a medical examiner stating that the commercial driver is physically qualified to operate a commercial motor vehicle. See appendix II for a description of the federal medical requirements. The National Transportation Safety Board (NTSB), an independent federal agency that investigates transportation accidents, considers the medical fitness of commercial drivers a major concern. Over the past several years, NTSB has reported on serious flaws in the medical certification process of commercial drivers. NTSB stated that these flaws can lead to increased highway fatalities and injuries for commercial vehicle drivers, their passengers, and the motoring public. In 2001 NTSB recommended eight safety actions to improve the oversight of the medical certification process, in response to a bus crash that killed 22 people in Louisiana. According to NTSB, currently all eight of the recommendations remain open. In response to FMCSA's failure to adequately address NTSB's recommendations, NTSB placed the oversight of medical fitness on its "Most Wanted" list in 2003. Table 1 details each of NTSB's recommendations. Several fatality crashes highlight the need for and the importance of having an effective medical certificate process. For example, In July 2000, a truck collided with a Tennessee Highway Patrol vehicle protecting a highway work zone. The patrol car exploded at impact, killing the state trooper. The driver of the truck had previously been diagnosed with sleep apnea and hypothyroidism, and had a similar crash in 1997, when he struck the rear of a patrol car in Utah. NTSB stated that it believes that if a comprehensive medical oversight program been in place at the time of the accident, this driver, with known and potentially incapacitating medical conditions, would have been less likely to have been operating a commercial vehicle. This accident, the NTSB said, "demonstrates how easily unfit drivers are able to take advantage of the inadequacies of the current medical system, resulting in potentially fatal consequences." In May 2005, a truck collided with a sports utility vehicle in Kansas killing a mother and her 10-month-old baby. Prior to the accident, a physician diagnosed the truck driver with a severe form of sleep apnea. The truck driver subsequently went to another physician who issued the medical certificate because the driver did not disclose this illness. The truck driver was found guilty of two counts of vehicular manslaughter. In August 2005 in New York, a truck collided with a motor vehicle, killing the occupants. The truck driver admitted to forging a medical certificate required to get his CDL license because he had been diagnosed with a seizure disorder. The truck driver recently pled guilty of two counts of manslaughter. Commercial drivers with serious medical conditions can still meet DOT medical fitness requirements to safely operate a commercial vehicle and thus hold CDLs. However, there is general agreement that careful medical evaluations are necessary to ensure that serious medical conditions do not preclude the safe operation of a commercial vehicle. It is impossible to determine from data analysis which commercial drivers receiving disability benefits have a medical condition that precludes them from safely driving a commercial vehicle because medical determinations are largely based on subjective factors that are not captured in databases. As such our analysis provides a starting point for exploring the effectiveness of the current CDL medical certification process. Our analysis of DOT data and disability data from the four selected federal agencies, SSA, VA, OPM, and DOL, found that about 563,000 individuals had been issued CDLs and were receiving full medical disability benefits. This represented over 4 percent of all CDLs in the DOT database. However, because DOT's database does include drivers that had suspended, revoked, or lapsed licenses, the actual number of active commercial drivers that receive full federal disability benefits cannot be determined. Also, our analysis does not include drivers with severe medical conditions that are not in the specific disability programs we selected. The majority of the individuals with serious medical conditions from our 12 selected states had an active CDL. Specifically, as shown in figure 1, of the 563,000 CDL holders receiving full disability benefits, about 135,000 of those individuals were from our 12 selected states. About 114,000 of these 135,000 individuals, or about 85 percent, had an active CDL according to CDL data provided by the 12 selected states. Further, our analysis of the state CDL data indicates that most of the licenses were issued after the commercial driver was found to be eligible for full disability benefits. Specifically, about 85,000 of the 135,000 individuals, or about 63 percent, had their CDL issued after the federal agency determined that the individual met the federal requirements for full disability benefits according to data from our four selected federal agencies. See appendix III for details for each selected state for the number of (1) commercial drivers with active CDLs, (2) commercial drivers with an active CDL even though they had a medical condition from which they received full federal disability benefits, and (3) commercial drivers that were issued a CDL after the driver was approved for full federal disability benefit payments. Because much of the determination of the medical fitness of commercial drivers relies on subjective factors, and because there are ways to circumvent the process (as shown below), it is impossible to determine the extent to which these commercial drivers have a medical condition that would preclude them from safely driving a commercial vehicle. As such our analysis provides a starting point for exploring the effectiveness of the current CDL medical certification process. However, because these individuals are receiving full disability benefits, it is likely that these medical conditions are severe. Further, our analysis also showed that over 1,000 of these drivers are diagnosed with vision, hearing, or seizure disorders, which are medical conditions that would routinely deny the granting of a CDL. Our investigations detail examples of 15 cases where careful medical evaluations did not occur on commercial drivers who were receiving full medical disability benefits. The case studies were selected from approximately 30,000 individuals from Florida, Maryland, Minnesota, and Virginia that had their CDL issued after the federal agency determined that the individual met the federal requirements for full medical disability benefits. For all 15 cases, we found that the states renewed the drivers' CDLs after the drivers were found by the federal government to be eligible for full disability benefits. For more detailed information on criteria for selection of the 15 cases, see appendix I. On the basis of our investigation of these 15 cases, we identified instances where careful medical examinations did not occur. Most states do not require commercial drivers to provide medical certifications to be issued a CDL. Instead, many states only require individuals to self-certify that a medical examiner granted them a medical certification allowing them to operate commercial vehicles, thus meeting the minimum federal requirements. As a result, we found several commercial drivers who made false assertions on their self-certification that they received a medical certification when in fact no certification was made. For more information on state requirements for medical certifications, see appendix IV. In addition, our investigations found that commercial drivers produced fraudulent documentation regarding their medical certification. Specifically, we found instances where commercial drivers forged a medical examiner's signature on a medical certification form. In addition, we also found a driver who failed to disclose to the medical examiner that another doctor had prescribed him morphine for his back pain. Finally, our investigations found certain medical examiners did not follow the federal requirements in the determination of medical fitness of commercial drivers. For example, one medical examiner represented to GAO that she did not know that a driver's deafness would disqualify the individual from receiving a medical certification. Table 2 highlights 5 of the 15 drivers we investigated. For all cases we investigated, the CDL was issued after the driver's disability benefits started. Appendix V provides details on the other 10 cases we examined. We are referring all 15 cases to the respective state driver license agency for further investigation. The following provides illustrative detailed information on three of the cases we examined. Case 1: A bus driver in Maryland has been receiving Social Security disability benefits since March 2006 due to his heart conditions. Specifically, the driver had open heart surgery in 2003 to repair a ruptured aorta, had a stroke in 2005, and shortly thereafter had another surgery to replace a heart valve. In June 2006, approximately 3 months after Social Security determined the driver was fully disabled; the Maryland driver license agency renewed his CDL for 5 years with a "Passenger" endorsement. The bus driver provided our investigator a forged medical certificate. Specifically, we found that the medical certificate did not have the required medical license number, the physician did not have any record that the bus driver underwent a medical examination for a CDL, and the physician denied conducting a CDL medical exam or signing the medical certificate. Surprisingly, the medical practice also had a copy of the forged medical certificate in its files. The medical practice's staff stated, however, that it is not uncommon for a patient to bring documents to the office and ask that they be stored in their medical records. The driver's CDL does not expire until 2011. Case 2: A Virginia truck driver has received SSA disability benefits for over 10 years. The driver's disability records indicate that that driver had multiple medical conditions, including complications due to an amputation, and that the driver is "also essentially illiterate." The truck driver has a prosthetic right leg resulting from a farm accident. Although the driver possesses a current medical certificate, the medical examiner did not specify on the medical certificate that it is only valid when accompanied with a Skills Performance Evaluation (SPE) certificate. To test his prosthetic leg, the truck driver stated that he was asked to push the medical examiner across the room in a rolling chair with the prosthetic leg. In our investigation, we attempted to contact the medical examiner but discovered that he is no longer employed by that clinic. The state revoked his medical license due to illegally distributing controlled substances. In 2006, the truck driver was involved in a single vehicle accident when the load in his truck shifted when making a turn and the truck overturned. Prior to October 2007, the truck driver had a CDL with both "Tanker" and "Hazmat" endorsements. In October 2007, the state driver license agency renewed his CDL with a "Tanker" endorsement, which will not expire until 2012. Case 3: A bus driver has been receiving Social Security disability benefits since 1994 for chronic obstructive pulmonary disorder (COPD). The bus driver currently uses three daily inhalers to control his breathing and has a breathing test conducted every 6 months. The bus driver stated that he "gets winded" when he walks to his mailbox and he "occasionally blacks out and forgets things." However, the driver stated that he has no problem driving a bus, however, he cannot handle luggage or perform any other strenuous duties. Despite not possessing a valid medical certificate, companies continue to hire him as a bus driver on an ad hoc basis. For example, the driver drove a passenger bus as recently as 1 month prior to the time of our interview. The driver stated that the companies have not asked to see his medical certificate. He further stated that because most companies are "hurting for drivers," they "don't ask a lot of questions" and pay many of their drivers in cash. The driver's CDL expires in 2010. We provided a draft of our report to DOT for review and comment. We received e-mail comments on the draft on June 16, 2008, from FMCSA's Office of Medical Programs. In FMCSA's response, FMCSA stated that our first objective implies that individuals who are fully disabled have severe medical conditions that may also prevent safe driving. FMCSA stated the following: Disability, even full disability associated with a diagnosis, does not necessarily mean that an individual is medically unfit to operate a commercial vehicle. Disability is not related necessarily to when a medical condition occurred or recurs. The onset of a disease or disabling medical condition is more relevant to medical fitness than when the disability benefits and payments began. As an example, a fully disabled individual may have accommodated to the disability and may improve with treatment while receiving lifelong disability payments. In general, a medical diagnosis alone is not adequate to determine medical fitness to operate a commercial vehicle safely. As an example, multiple sclerosis, while disabling, has several progressive phases, and is not necessarily disqualifying. In addition, FMCSA did not believe that we accurately characterized the 15 cases where careful medical evaluations did not occur. FMCSA stated that this implies these drivers were evaluated by someone for medical fitness for duty, but in 9 cases, the driver was not certified or not evaluated by a medical examiner. We believe our report clearly acknowledges that it is impossible to determine the extent to which these commercial drivers have medical conditions that would preclude them from safely driving a commercial vehicle. In the report, we state that commercial drivers with serious medical conditions can still meet DOT medical fitness requirements to safely operate a commercial vehicle and thus hold CDLs. Further, our report acknowledged that because medical determinations rely in large part on subjective factors that are not captured in databases, it is impossible to determine from data mining and matching the extent to which commercial drivers have a medical condition that precludes them from safely driving a commercial vehicle and therefore if the certification process is effective. Thus, our analysis provides a starting point for exploring the effectiveness of the current CDL medical certification process. We also believe that we fairly characterize that all 15 cases did not have a careful medical evaluation. For all 15 cases that we reviewed, we found that the medical evaluation was not adequate or did not occur. Thus, we conclude that a careful medical evaluation did not occur for all 15 drivers in our case studies. FMCSA also provided us a technical comment which we incorporated in the report. As agreed with your offices, unless you publicly release its contents earlier we plan no further distribution of this report until 30 days from its date. At that time, we will send copies of this report to the Secretary of Transportation. We will make copies available to others upon request. In addition, the report will be available at no charge on the GAO Web site at http://www.gao.gov. Please contact me at (202) 512-6722 or kutzg@gao.gov if you have any questions concerning this report. Contact points for our Offices of Congressional Relations and Public Affairs may be found on the last page of this report. GAO staff who made key contributions to this report are listed in appendix VI. To determine to the extent possible the number of individuals holding a current commercial driver license (CDL) who have serious medical conditions, we presumed that individuals receiving full federal disability benefits were eligible for these benefits because of the seriousness of their medical conditions. As such, we obtained and analyzed the Department of Transportation's (DOT) Commercial Driver License Information System (CDLIS) database as of May 2007. For the Social Security Administration (SSA) and the Department of Veterans Affairs (VA) we provided the CDLIS commercial driver information to those agencies. SSA and VA then matched the commercial drivers to the individuals receiving benefits for their disability programs and provided us those results. We also obtained and analyzed the recipient files for four additional federal disability programs. These include the Office of Personnel Management's (OPM) civil service retirement program and the three programs administered by the Department of Labor: Black Lung, Federal Employee Compensation Act, and the Energy Employees Occupational Illness Compensation Program. We matched the CDL holders from CDLIS to the four federal disability recipient files based on social security number, name, and date of birth. We further analyzed the CDL and disability data to ensure that the commercial drivers met the following criteria: the individual must be currently receiving disability benefits, and the individual must be identified as 100 percent disabled according to the program's criteria. Because CDLIS is an archival database, the CDLIS data contain information on expired CDLs. To identify the active drivers within CDLIS, we obtained CDL data from a nonrepresentative selection of 12 states. The 12 selected states, representing about 42 percent of all CDLs contained in CDLIS, are: California, Florida, Illinois, Kentucky, Maryland, Michigan, Minnesota, Montana, Tennessee, Texas, Virginia, and Wisconsin. The 12 states were selected primarily based on the size of the CDL population. Because commercial drivers may contract a serious medical condition after the issuance of the CDL, we also determined the number of individuals that received their CDL subsequent to when the federal agencies determined the individual to be eligible for full disability benefits. Our estimate does not include drivers with severe medical conditions that are not in the selected programs we analyzed. We matched the 12 state CDL files to the six CDLIS-disability match files based on driver license number, and identified those CDLs that were current based on license status. To provide case-study examples of commercial drivers who hold active CDLs while also receiving federal disability payments for a disqualifying medical condition, we focused on four states--Florida, Maryland, Minnesota, and Virginia. From these four states, we selected, in a nonrepresentative fashion, 15 commercial drivers for detailed investigation. We identified these driver cases based on our data analysis and mining. For each case, we interviewed, as appropriate, the commercial driver, the driver's employer, and the driver's physician to determine whether the medical condition should have precluded the driver from holding a valid CDL. For these 15 cases, we also reviewed state department of motor vehicle reports, police reports, and other public records. To determine the reliability of DOT's CDLIS data, we used SSA's Enumeration and Verification System to verify key data elements in the database that were used to perform our work. For the federal disability databases, we assessed the reliability of the data from SSA and VA, which comprise 99 percent of the CDLIS-disability matches. To verify its reliability, we reviewed program logic used by the agencies to match the CDLIS data with their federal disability recipients. We also reviewed the current Performance and Accountability Reports for the agencies to verify that their systems had successfully undergone the required stewardship reviews. For the 12 selected states' CDL databases, we performed electronic testing of the specific data elements in the database that were used to perform our work. In addition, for 5 of the 12 states we verified the query logic used to create the CDL extract files. For the other 7 states we were unable to obtain the query logic. We performed our investigative work from May 2007 to June 2008 in accordance with standards prescribed by the President's Council on Integrity and Efficiency. Federal regulations require that commercial drivers be examined and certified by a licensed medical examiner, such as licensed physician, physician's assistant, and nurse practitioner, to ensure they meet minimum physical qualifications prior to driving. It is the responsibility of both drivers and motor carriers employing drivers to ensure that drivers' medical certificates are current. According to federal regulations, the medical examiner must be knowledgeable about the regulatory physical qualifications and guidelines as well as the driver's responsibilities and work environment. In general, the medical certification procedures include the following steps: The driver completes and certifies a medical certification form that includes information about the driver's health history. The form is provided to the medical examiner as part of the examination. The medical examiner discusses the driver's health history and the side effects of prescribed medication and common over-the-counter medications. The medical examiner tests the driver's vision, hearing, blood pressure, pulse rate, and urine specimen (for testing sugar and protein levels). The medical examiner conducts a physical examination and makes a determination on driver fitness. If the medical examiner determines the driver is fit to drive, he/she signs the medical certificate, which the driver must carry with his/her license. The certificate must be dated. The medical examiner keeps a copy in his/her records, and provides a copy to the driver's employer. When the medical examiner finds medical conditions that prevent certification of the physical condition of the driver and this finding is in conflict with the findings of another medical examiner or the driver's personal physician, the driver can apply to the Federal Motor Carrier Safety Administration (FMCSA) for a determination. Federal regulations and the accompanying medical guidance provide criteria to the medical examiners for determining the physical condition of commercial drivers. Although the medical examiner makes the determination as to whether the driver is medically fit to operate a commercial vehicle, the following provides a general overview of the nature of the physical qualifications: no loss of physical limbs, including a foot, a leg, a hand, or an arm; no impairment of limbs that would interfere with grasping or their ability to perform normal tasks; no established medical history or clinical diagnosis of diabetes currently requiring insulin for control, respiratory dysfunction, or high blood pressure that would affect their ability to control or drive a commercial motor vehicle; no current diagnosis of a variety of coronary conditions and cardiovascular disease including congestive heart failure; no mental disease or psychiatric disorder that would interfere with their ability to drive a commercial vehicle safely; has distant visual acuity and hearing ability that meets stated does not use a controlled substance or habit-forming drug; and has no current clinical diagnosis of alcoholism. When operating a commercial motor vehicle, drivers must have a copy of the medical examiner's certificate in their possession. Motor carriers, in turn, are required to maintain a copy of the certificate in their files. When drivers are stopped for a roadside inspection, state inspectors can review the medical examiner's certificate. During compliance reviews of motor carriers, FMCSA investigators may also verify the validity of medical certifications on file with the motor carrier. In the main portion of the report, we state that from the 12 selected states 114,000 commercial drivers had a current commercial driver license (CDL) even though they had a medical condition from which they received full federal disability benefits. Further, approximately 85,000, or about 63 percent of the active commercial drivers, were issued a CDL after the driver was approved for full federal disability benefit payments. Table 3 below provides details by each selected state on the number of (1) commercial drivers with active CDLs, (2) commercial drivers with an active CDL even though they had a medical condition from which they received full federal disability benefits, and (3) commercial drivers that were issued a CDL after the driver was approved for full federal disability benefit payments. The states have adopted different levels of control to verify that commercial driver license applicants meet the Department of Transportation (DOT) medical certification requirements. As shown in figure 2, 25 states, or 50 percent, allow drivers to self-certify that they meet the requirements. The self-certification is often simply a check-box on the application. Eighteen states, or 36 percent, require that the commercial driver show the DOT medical certificate to the driver licensing agency at the time of application. Further, 6 states, or 12 percent, not only require that the driver show the DOT medical certificate at the time of application but also maintain a copy of the certificate in the driving records of the applicant. Finally, 1 state did not respond to the inquiries. Table 2 in the main portion of the report provides information on five detailed case studies. Table 4 shows the remaining case studies that we investigated. As with the five cases discussed in the body of this testimony, we found drivers with a valid commercial driver license (CDL) who also had serious medical conditions. GAO staff who made major contributions to this report include Matthew Valenta, Assistant Director; Sunny Chang; Paul DeSaulniers; Craig Fischer; John V. Kelly; Jeffrey McDermott; Andrew McIntosh; Andrew O'Connell; Philip Reiff; Nathaniel Taylor; and Lindsay Welter.

Summary:
Millions of drivers hold commercial driver licenses (CDL), allowing them to operate commercial vehicles. The Department of Transportation (DOT) established regulations requiring medical examiners to certify that these drivers are medically fit to operate their vehicles and provides oversight of their implementation. Little is known on the extent to which individuals with serious medical conditions hold CDLs. GAO was asked to (1) examine the extent to which individuals holding a current CDL have serious medical conditions and (2) provide examples of commercial drivers with medical conditions that should disqualify them from receiving a CDL. To examine the extent to which individuals holding CDLs have serious medical conditions, GAO identified those who were in both DOT's CDL database and selected federal disability databases of the Social Security Administration, Office of Personnel Management, and Departments of Veterans Affairs and Labor and have been identified as 100 percent disabled according to the program's criteria. Because DOT's data also include inactive licenses, GAO obtained current CDL data from 12 selected states based primarily on the size of CDL population. To provide case study examples, GAO focused on four states--Florida, Maryland, Minnesota, and Virginia. For 15 drivers identified from data mining, GAO interviewed, as appropriate, the driver, driver's employer, and driver's physician. GAO is not making any recommendations. Commercial drivers with serious medical conditions can still meet DOT medical fitness requirements to safely operate a commercial vehicle and thus hold CDLs. However, there is general agreement that careful medical evaluations are necessary to ensure that serious medical conditions do not preclude the safe operation of a commercial vehicle. Because medical determinations rely in large part on subjective factors that are not captured in databases, it is impossible to determine from data matching and mining alone the extent to which commercial drivers have medical conditions that preclude them from safely driving a commercial vehicle and therefore if the certification process is effective. GAO's analysis provides a starting point for exploring the effectiveness of the current CDL medical certification process. Our analysis of commercial license data from DOT and medical disability data from the Social Security Administration, Office of Personnel Management, and Departments of Veterans Affairs and Labor found that about 563,000 of such individuals had commercial driver licenses and were determined by the federal government to be eligible for full disability benefits. This represented over 4 percent of all commercial driver licenses in the DOT database. Our analysis of 12 selected states indicates that most of these commercial drivers still have active licenses. Specifically, for these 12 selected states, about 85 percent had a current CDL even though they had a medical condition from which they received full federal disability benefits. The majority of these drivers were issued a CDL after the driver was approved for full federal disability benefit. Our investigations detail examples of 15 cases where careful medical evaluations did not occur on commercial drivers who were receiving full disability benefits for serious medical conditions.