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NTSB Cites Driver Fatigue, Improper Seat-Belt Use Among Causes of Fatal School-Bus Crash

DeborahHersmanpF4EY9hjdokmThe National Transportation Safety Board outlined investigators’ findings and called for change in a board meeting covering newly released highway accident reports on two fatal bus collisions: the first in Chesterfield, N.J., on Feb. 16, 2012, and the second in Port St. Lucie, Fla., a month later.

Each accident resulted in the death of one child passenger and caused severe injuries to others on the bus, including the driver.

“These two school bus crashes were similar in several respects,” said NTSB Chairman Deborah Hersman in her opening remarks on July 23. “Both were side-impact crashes. Both were in states that require seat belts on school buses, and in both crashes, properly worn lap belts were beneficial.”

The NTSB’s lengthy, in-depth investigation found that bus-driver impairment played a larger role in the New Jersey school bus accident than previously believed. Driver John Tieman, 66, was exhausted from lack of sleep, taking multiple pain medications and suffering from persistent back pain that prevented him from turning and fully scanning the intersection.

“The school bus driver was fatigued due to acute sleep loss, chronic sleep [sic], and poor sleep quality associated with medical conditions and alcohol use, the side effects from prescription medications, and the synergistic effect of these factors,” the board stated in its final summary of findings. “The fatigue contributed to reduced vigilance and detection of the approaching truck.”

In addition, the board reported the school bus driver failed to disclose vital information about his medical condition, a complete list of his medications and his history of alcoholism. Yet the report noted that testing revealed there was no alcohol in his system at the time of the crash.

On Feb. 16, 2012, there were 25 elementary students on the Chesterfield school bus when it collided with a 2004 Mack truck with a dump container carrying broken asphalt at the Bordentown-Chesterfield Road (BCR 528) intersection. The front of the dump truck slammed the left rear of the bus, spinning it around until it struck a utility pole. Eleven-year-old Isabelle Tezsla was killed and her triplet sisters severely injured, along with 13 others who sustained minor to serious injuries.

Though the NTSB determined the school bus driver erred in entering the intersection too soon, the board clarified that speeding by the dump truck driver and vehicle defects also played a role in the fatal accident.

“Contributing to the severity of the crash was the truck driver’s operation of his vehicle in excess of the posted speed limit in addition to his failure to ensure that the weight of the vehicle was within allowable operating restrictions,” stated the hearing transcript. “Further contribution to the severity of the crash were the defective brakes on the truck … and overweight condition due to poor oversight by Herman’s Trucking.”

Call for Seat Belts, More Training

During its discussion about occupant protection systems on the school bus, the board stressed that though school buses remain the safest vehicle on the road, other features such as seat belts can make them even safer.

According to the hearing transcript, “The school buses are extremely safe without any sort of belt system on them. It is only in these severe cases where you see a school bus that is hit by another very large vehicle, where you are going to need something additional, and that is where we see that the properly worn lap belts are beneficial and the harness makes them safer.”

In addition, the board stated that in severe side-impact crashes such as those in Chesterfield, N.J. and Port St. Lucie, Fla., properly worn lap and shoulder belts reduce injuries related to upper body flailing and thus provide the best protection for student riders.

Also of note were findings that the fatally and severely injured passengers were seated in the back half of the school bus in the area of greater impact and that some students either wore their lap belts improperly or not at all. Victim Isabelle Tezsla was most likely unbelted.

“We have provided standards to ensure that the belts, if they are installed on the buses, are installed properly and can be adjusted properly and fit children of a variety of different ages. Now we just have to make sure that people understand the importance of these belts and that they wear them properly all the time,” members of the board concluded.

They pointed out that because of the Port St. Lucie video, investigators actually had information about that bus driver and how as the children boarded the bus, he instructed them to buckle up and he continued to reinforce that during the ride, telling them to get back in proper seating position.

Members briefly touched on whether the technology exists to monitor child-passenger seatbelt usage yet noted it would be difficult to detect if there is an person in a seat since school buses do not always have full occupancy. They also pointed out such technology would likely be cost-prohibitive.

Tied to this observation was the point that cost also remains the biggest impediment to equipping all new school buses with seat belts of any kind.

“We would like to see less of a patchwork system across our country with respect to school bus restraints, but if schools are going to make decisions, we would want them to consider belts and to prioritize that lap-shoulder belts are the best,” they stated.

The board concluded with the following recommendations to state officials and student transportation organizations;

1. To the states of California, Florida, Louisiana, New Jersey, New York, and Texas, which have laws mandating seat belts on all new school buses:

  • Develop a handout for school districts to distribute annually to students and parents about the importance of the proper use of all types of school-bus seat belts, including the potential harm of not wearing them or not adjusting them properly, and
  • Provide training procedures for schools to follow during twice yearly drills to show students how to wear seat belts properly.

2. To NASDPTS, NAPT, NSTA, the School Bus Manufacturer’s Technical Council and the National Safety Council’s School Transportation Section:

  • Develop guidelines and include them in the next update of the National School Transportation Specifications and Procedures manual to assist schools in training bus drivers on the students and in educating parents on the importance of proper use of school bus seat belts.
  • Provide association members with educational materials on the lap-shoulder belts, providing the highest level of protection for school bus passengers come and
  • Advise states and/or school districts to consider these a safety benefit when purchasing seat belt–equipped school buses.

In response to the safety board’s recommendations, NAPT President Michael Martin said the NTSB’s lengthy investigation and summation added valuable new information to the discussion about improving passenger crash protection in a school bus. 

“We look forward to working with the NTSB and the National Highway Traffic Safety Administration to evaluate the practicability of implementing the recommendations that have been offered today,” added Martin.

NSTA echoed his remarks and emphasized that the board’s guidance on occupant restraint systems for large school buses matches the stance the association has taken since 2007.

“NSTA’s Statement on Occupant Protection notes that the proper usage of seat belts is very important and recommends that any requirement for safety restraints should include a mandate for usage and a mandate that school districts include training on the proper use and adjustment of lap/shoulder belts in their annual school bus safety training,” said NSTA President Tim Flood. “We are grateful that the NTSB has validated our long-standing recommendations.”

To view the NTSB’s synopsis of findings, probable-cause determination and recommendations stemming from the Chesterfield, N.J., bus-truck collision, click here. The board plans to release its full report in about three weeks.

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