The National Transportation Safety Board (NTSB) has adopted a new recommendation to require fire suppression systems in all new school buses—and to retrofit those already in use. The decision is in response to a fatal December 2017 fire in Oakland, Iowa that killed the driver and a 16-year-old student.
The initial recommendation to the National Highway Traffic Safety Administration (NHTSA) limited the equipment to newly manufactured school buses and extended the recommendation to all school bus manufacturers. But the board approved board member Jennifer Homendy’s amendment that the recommendations extend that requirement to retrofitting all existing school buses with fire suppression systems.
NTSB’s investigation concluded that had the Riverside Community School District bus had a fire suppression system installed in the engine compartment, it could have provided additional time for 74-year-old driver Donnie Hendricks and student Megan Klindt to safely evacuate.
“The more time, the better the evacuation will be,” said NTSB investigator Michele Beckjord. “You’re never going to prevent all fires, but what you can do is if the fire does occur, to quickly put it out and to keep it from reflashing.”
NTSB also urged NHTSA to develop a standard to improve the construction of firewalls between school bus engine compartments and the passenger compartment to limit the passage of toxic gases and heat. The investigation concluded that the gases and heat led to the incapacitation of the bus driver and student, which led to their deaths.
It also asked NHTSA to update Federal Motor Vehicle Safety Standard 302 on interior flammability.
NTSB also found that about 1.2 school bus fires occur each day.
A total of 18 probable causes of the fatal fire were provided, resulting in the 10 new recommendations being issued during the NTSB board meeting on Tuesday, June 18 in Washington, D.C.
The fire started when Hendricks was backing up the bus out of Klindt’s driveway and into a ditch alongside the road. The bus became stuck, and Hendricks repeatedly tried to free the bus. Investigators concluded that the origin of the fire was likely an overheated turbocharger, and a blocked exhaust pipe acted as a contributing factor. Flammable fluids in the engine further fueled the fire.
In addition, NTSB investigators found that Hendricks was physically unfit for duty, due to a chronic back condition. He was also taking the prescription Gabapentin for pain, had a back surgery scheduled for the following week—and was unable to walk unassisted. The report said that Klindt likely attempted to help Hendricks out of his seat but was soon overcome by the heat and fumes.
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NTSB Asked that all States Revise Their Driver Standards
As a result, the NTSB asked the 50 states and U.S. territories to revise their standards for school bus drivers. Those standards would require that new applicants pass physical fitness tests upon hire and then again annually, as well as after any new medical condition is diagnosed. NTSB recommended that Iowa, in particular, inform all of its school districts of the lessons learned from the investigation, how to report bus drivers with medical conditions and who are physically unable to perform their duties.
“This is an issue of keeping physically fit drivers on the road and unfit drivers off the road,” said NTSB Chair Robert Sumwalt.
NTSB placed considerable blame on Hendricks’ employer, the Riverside Community School District, for lack of oversight and not removing the driver from active duty.
“If the Riverside Community School District had adhered to requirements of school bus policies regarding the physical abilities of drivers and had not allowed the driver to operate a bus until he was medically cleared and fit for duty or could pass a physical performance test, the fatal outcome of what should have been a survivable run off the road would have been avoided,” said Sumwalt.
Sumwalt concluded that “We clearly established that a school district has the responsibility to provide oversight and keep drivers who should not be driving, off the road. This is not discrimination. This is an issue of keeping physically fit drivers on the road and unfit drivers off the road.”
Sumwalt commented that he was reminded of last year’s report on the Baltimore and Chattanooga crashes, which termed both respective incidents as a result of a lack of oversight by the school district and the school bus contractor. “If we’re going to just sit around and make a point, we’ve got to do it. And by putting them in the probable cause it sends that pin and that the NTSB is going to call it the way we see it. And you will be named in the probable cause.”
NTSB also recommended that the Iowa district advise all of its school bus drivers on the proper use of the onboard 911 button, in the event of an emergency. The investigation found that when the fire started, Hendricks radioed dispatch instead of activating the button.
NTSB also recommended to the National Association of State Directors of Pupil Transportation Services, National Association for Pupil Transportation and National School Transportation Association, that they verify through their respective members that students across the U.S. are trained on how to operate the manual release on school bus loading doors during an emergency.
Earl Weener, who attended his final NTSB meeting as a board member on Tuesday, asked crash experts in the room if anyone has looked at how to prevent school bus fires. “Are there measures to be taken to prevent bus fires?” he asked.
NTSB investigator Michele Beckjord replied that “School buses are driven hard, so one of the things to be recognized is maintenance that needs to be done. [You may] never be able to completely prevent fires such as in engines, with chafing of fires, but when fires do occur, mitigation can prevent fires from [starting, such as] fire suppression systems and firewalls. What we were comparing is the ability to introduce fireproof materials. We’ve proposed fire suppression systems to allow drivers enough time to pull over and evacuate students.”
Beckjord added, “The more time [there is], the better the evacuation will be. You are never going to prevent all fires, but what you can do is if the fire does occur, to quickly put it out and to keep it from reflashing,” he concluded.
List of 18 Contributing Factors to the Fatal Incident
- School bus mechanical, driver condition, DL.
- The emergency response was adequate and timely.
- The driver failed to control the school bus.
- The likely origin of the fire was the turbocharger.
- The blocked exhaust pipe ignited the fire.
- Fluids in the engine fueled the fire.
- The passenger was attempting to assist the driver, who had limited capability, but the passenger was overcome.
- The school bus driver had progressive chronic pain, but there was no evidence that his condition or a prescription drug would have affected the driver functions while sitting.
- It is likely that the driver’s back disease impaired his ability to evacuate or assist the student.
- Physical tests are needed.
- Riverside Community School District exercised poor oversight of the driver because he had limited ability [to drive safely].
- Awareness training for Iowa personnel would increase awareness of commercial driver fitness.
- A fire suppression system in the engine compartment was needed.
- The lack of a complete firewall between the engine and passenger compartments allowed super-hot gasses.
- Once a school bus compartment is breached, even an external fire spreads quickly, and heat and [hot] gasses will overcome passengers.
- The bus driver should have activated the panic button instead of calling dispatch.
- Emergency training of students is vital.
- Despite the front loading door being the first means of egress, students might not be trained in how to evacuate through a manually operated door, if the driver becomes incapacitated.
Editor’s Note: David George contributed to this report.