The National Transportation Safety Board published its final report and recommendations on the 2016 Baltimore and Chattanooga school bus crashes, as board members highlighted areas of concern and room for improvement.
The NTSB clarified that it did not place blame for the two traffic crashes, but had a “mission to improve transportation safety by investigating accidents and incidents and issuing safety recommendations.”
Most notably during its May 22 meeting announcing the investigation conclusions, as previously reported by School Transportation News, NTSB recommended that states should require lap/shoulder belts on all sizes of school buses, that manufacturers should install Electronic Stability Controls on all buses, and that the National Highway Traffic Safety Administration should mandate collision avoidance technology with automatic braking. NHTSA was also encouraged to develop standards for Electronic Stability Controls and on-board data recorders and mandate them as well.
IC Bus was also specifically advised to install data recorders to capture data in the event of a crash. There was no such recorder on the 2015 IC Bus school bus involved in the Baltimore crash, so data was gathered from cameras on the transit bus it struck and nearby video surveillance, as well as from on-scene evidence.
NTSB determined that the school bus driver, Glenn Chappell, caused the crash after having a seizure, several of which he’d had while on the job. NTSB counted 10 separate crashes in which Chappell had been involved, some of which resulted from his seizures, during the five years that he had spent working for five different school bus companies prior to the fatal crash on Nov. 1, 2016.
The state of Maryland was given specific recommendations relating to improved documenting and reporting of health conditions by medical providers and driver disqualification by the state Department of Education.
Member Earl Weener said he was pleased to see school bus driver medical conditions and reporting discussed since “the reality is that pre-employment or licensing-based
screenings rely on the candor of the person being assessed.” This, he added, requires medical providers to not only be proactive in reporting medical conditions, but also to pay attention to the occupations of the people they treat.
“We are all responsible for reporting unsafe drivers. Each state driver licensing authority has a medical review board. Anyone can call to ask questions about reporting an unsafe driver. To borrow from security messaging, if you see something, say something,” he advised.
NTSB also recommended changes to Maryland’s Motor Vehicle Association and use of facial recognition technology to combat fraud of the type Chappell allegedly engaged in. He obtained four different driver’s licenses by using different birth dates and names.
Johnthony Walker, the driver in the Chattanooga crash also had a problematic history. On-board video on the 2008 Thomas Built Bus school bus he was driving showed him using his phone while students were loading, and phone records showed he was on an active call during the crash, in violation of Tennessee state law.
Within three months on the job, complaints had been filed against Walker by the Woodmore Elementary School principal and his own supervisor at contractor Durham School Services, mostly about his speeding and poor driving. NTSB found that the unsafe driving behaviors that caused the crash began after Walker was told to stop submitting so many student behavior reports.
“The NTSB concludes that, in attempting to control student behavior, the Chattanooga school bus driver had previously operated the bus in a manner that caused passengers to fall or be thrown from their seats, and that his precrash steering behaviors and speeding were consistent with these unsafe driving patterns,” the report stated.
NTSB also said that six students had complained about Walker’s driving five days prior to the crash, but that the Durham terminal manager had not finished reviewing the bus video before the crash. When he returned to do so, the video did indeed show students being jostled around.
Walker’s speed, the curve of the road he was travelling on, and his limited driving experience all contributed to the loss of control and fatal crash on Nov. 21, 2016. There was also a white van on the scene as Walker claimed in court, but NTSB determined that its possible contribution to the crash was not as significant as his speeding.
Both bus contracting companies were also identified as failing in their duties. AAAfordable Transportation, the contractor for Baltimore City Public Schools, “did not conduct an adequate background check” on Chappell, “overlooked high-risk driver events,” including an on-the-job seizure, and “exercised poor driver safety oversight by allowing a known medically unfit driver to operate a school bus.”
Durham School Services, meanwhile, did not have a centralized system for collecting complaints about its drivers in Chattanooga, and did not follow-up with Walker on those that they did receive. NTSB also found that the Hamilton County Board of Education failed to provide adequate oversight of Durham and to ensure the company’s drivers were safe.
NTSB added that a system implemented by Durham after the crash includes an “electronic portal (that) allows both school system employees and Durham management to record complaints, collects the information in a central database, logs the response actions, and documents disciplinary or training actions in the driver’s employee file.”
It was also noted that Baltimore City Public Schools did not conduct post-crash interviews with Chappell, and lacked a consistently-enforced discipline procedure. NTSB recommended last March that the transportation department undergo an audit by an independent third party and accept the resulting safety recommendations.
“Better bus driver oversight, including measures such as implementing better processes for tracking driver complaints and medical issues to ensure bus drivers are qualified and safe before they get behind the wheel, could have prevented these tragedies,” summed up member T. Bella Dinh-Zarr.
“By combining these two crashes into a single report, the NTSB Highway Safety staff has shown that these crashes were not simply problems isolated to Chattanooga or Baltimore City, but rather systemic issues that could be found in many school districts across our country,” explained Dinh-Zarr. “In both crashes, the investigation highlighted school districts’ lack of oversight of student transportation service providers, poor management of unsafe school bus drivers by the motor carriers and school districts, and lack of electronic stability control, automatic emergency braking, and event data recorders.”
Safety technology like lap/shoulder belts, ESC and collision mitigation technology were identified as helpful factors that would have mitigated the severity of these crashes.
“Although many school buses are designed with compartmentalization as the sole occupant protection system, precrash, lateral, and rollover motions still expose unbelted passengers to injury-producing components within the vehicle, to intrusion, to movement out of the seating compartment, and to ejection,” NTSB noted. It added that NHTSA had found over 50 percent of school transportation vehicle crashes from 2007 to 2016 were not frontal.
The National Association of State Directors of Pupil Transportation Services encouraged its members to review the final report and said it would do so at next month’s board meeting at the STN EXPO in Reno, Nevada.
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