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Safety Recommendation Details

Safety Recommendation H-09-007
Details
Synopsis: On January 6, 2008, about 3:15 p.m. mountain standard time, a 2007 Motor Coach Industries 56-passenger motorcoach with a driver and 52 passengers on board departed Telluride, Colorado, en route to Phoenix, Arizona, as part of a 17-motorcoach charter. The motorcoach passengers were returning from a 3-day ski trip. The normal route from Telluride to Phoenix along Colorado State Route 145 was closed due to snow, and the lead driver planned an alternate route that included U.S. Route 163/191 through Utah. About 8:02 p.m., the motorcoach was traveling southbound, descending a 5.6-percent grade leading to a curve to the left, 1,800 feet north of milepost 29 on U.S. Route 163. The weather was cloudy, and the roadway was dry at the time of the accident. After entering the curve, the motorcoach departed the right side of the roadway at a shallow angle, striking the guardrail with the right-rear wheel and lower coach body about 61 feet before the end of the guardrail. The motorcoach traveled approximately 350 feet along the foreslope (portion of roadside sloping away from the roadway), with the right tires off the roadway. The back tires lost traction as the foreslope transitioned into the drainage ditch.
Recommendation: TO THE FEDERAL HIGHWAY ADMINISTRATION: Develop and implement, in conjunction with the American Association of State Highway and Transportation Officials and the National Association of State Emergency Medical Services Officials, criteria based on traffic patterns, passenger volume, and bus types that can be used to assess the risks of rural travel by large buses. Use these criteria as part of the SAFETEA-LU requirement to identify and select Highway Safety Improvement Program projects.
Original recommendation transmittal letter: PDF
Overall Status: Closed - Exceeds Recommended Action
Mode: Highway
Location: Mexican Hat, UT, United States
Is Reiterated: No
Is Hazmat: No
Is NPRM: No
Accident #: HWY08MH012
Accident Reports: Motorcoach Rollover
Report #: HAR-09-01
Accident Date: 1/6/2008
Issue Date: 5/29/2009
Date Closed: 9/16/2015
Addressee(s) and Addressee Status: FHWA (Closed - Exceeds Recommended Action)
Keyword(s):

Safety Recommendation History
From: NTSB
To: FHWA
Date: 9/16/2015
Response: We are pleased by your collaboration with NASEMSO and AASHTO to create (1) a geographic information system-based motorcoach roadway assessment tool, (2) a nationwide motorcoach origin-destination data set, and (3) a guide to help states with including motor carrier and motorcoach activities in the highway safety plan process. We are also pleased by your work with the National 911 Office and the National Highway Traffic Safety Administration’s Office of Emergency Medical Services (EMS) to provide resources for collaboration between EMS and highway safety officials through the state highway safety plan. The actions you took exceeded our expectations in issuing this recommendation and constitute a long-term, state-of-the-art solution that provides states with solid data to allow them to properly assess rural road travel and hazardous locations, especially in remote areas where a tour or charter bus accident can result in large numbers of injured passengers. Accordingly, Safety Recommendation H-09-7 is classified CLOSED—EXCEEDS RECOMMENDED ACTION.

From: FHWA
To: NTSB
Date: 3/25/2015
Response: -From Gregory G. Nadeau, Deputy Administrator: In responding to the recommendation, FHW A points out that the process States use to select Highway Safety Improvement Program (HSIP) projects is aligned with the Statewide Transportation Improvement Program (STIP) and selected projects must advance a State's strategic highway safety plan (SHSP). The criteria for the eligibility of these funds are specified in law and cannot be changed at the discretion of FHW A. The FHW A has no authority in law to infringe on the rights of the States to select projects for Federal-aid funding, as long as the States comply with all program requirements. As indicated in our September 30, 2009, initial response letter, FHWA explored, with AASHTO and NASEMSO, various options to assist the States in addressing the challenges identified by the accident investigation. The NTSB found these initiatives to be an appropriate response and classified H-09-7 as Open-Acceptable Alternate Response. The initiatives included the following approaches: • Continue to work with AASHTO and NASEMSO to explore ways to improve the State's collection and use of exposure data on tour and charter motorcoach travel. • Explore the feasibility of collecting exposure data for tour and charter motorcoaches through the Highway Performance Monitoring System (HPMS). • Examine options to develop additional guidance to encourage and reinforce inclusion of State and local motorcoach industry representatives in the development of SHSPs. • Encourage consideration of motorcoach safety issues in the determination of HSIP priorities. • Examine strategies to encourage States, where appropriate, to use the 1 0 percent flex option for emergency medical services (EMS) programs that will mitigate response times and increase capacity in responding to motorcoach crashes. The FHW A has taken the following actions to complete the proposed alternate response initiatives. Working with AASHTO and NASEMSO, the FHWA developed a Motorcoach Roadway Safety Assessment Tool (Motorcoach RSAT) for States and industry professionals to use to identify and evaluate the safety of rural routes that motorcoaches use. The Motorcoach RSA T utilizes inputs from transportation and EMS professionals to measure crash risk along a route, as well as the robustness of communications, EMS response capabilities, and proximity to hospitals and trauma centers. The tool provides data visualization based on a geographic information system (GIS) platform that uses ArcGIS for processing data, through the Google Earth platform, by rating the selected route for safety as Blue (best) to Green, Yellow, Orange, and Red (worst). The FHWA is actively marketing the tool to States and motorcoach transportation safety stakeholders and it is available for download on the FHW A's Safety Web site (http: 1/safety.fhwa.dot.gov.frsat/). To enhance exposure data capabilities for motorcoach travel, FHWA has not only determined the feasibility of providing motorcoach specific exposure data, but has begun providing the data through the HPMS. In 2011, FHWA refined its data computation procedures for vehicle miles traveled (VMT) exposure to include a motorcoach VMT procedure. The procedure provides VMT estimates based on actual field monitored data. The new procedure was retroactively applied to revise 2008 and 2009 data and was additionally used to provide motorcoach VMT for 2010 and forward. The new VMT collection procedure can be found at http://www.fbwa.dot.gov/ohim/vm 1 methodology 2007.pdf. Further, FHW A has expanded its motorcoach data analysis beyond the traditional HPMS coverage and is in the process of completing a nationwide motorcoach origin destination (OD) data set for the first time in history. The OD data covers both tour and charter motorcoaches. A continuous motorcoach data program is being developed to cover nationwide passenger travel. A passenger OD and passenger VMT data method will be developed and provided beginning in 2017. New updates for the development and deployment of SHSPs were issued in May 2013 through the publication of Strategic Highway Safety Plans - A Champion 's Guidebook to Saving Lives, Second Edition" and included guidance for inclusion of motor carrier and motorcoach activities in the SHSP process. The Champion's guide is available on the FHWA's Safety Web site at http://safety.fhwa.dot.gov/hsip/shsp/guidebook/clunpgd.pdf. Additionally, the Moving Ahead for Progress in the 21 51 Century Act (MAP-21) required FHWA to make changes to the HSIP under 23 USC 148. The FHWA published a Notice of Proposed Rulemaking in the Federal Register on May 28, 2014. The proposed regulatory changes in 23 CFR 924.3, Definitions include "Representatives conducting a motor carrier safety program under section 31102, 31106, or 31309 of title 49" as safety stakeholders. The MAP-21 maintained the SHSP as a major component and requirement of the HSIP (23 USC 148) as a statewide-coordinated safety plan that provides a comprehensive framework for reducing highway fatalities and serious injuries on all public roads. The aforementioned inclusions of motor carrier and motorcoach specific guidance in the SHSP Champion's Guide and in the HSIP proposed regulation under MAP-21 encourages consideration of motorcoach safety issues within the data driven requirements to ultimately program projects in the STIP. The HSIP, under MAP-21, identifies highway safety improvement projects as any strategy, activity or project on a public road that is consistent with the data-driven SHSP and corrects or improves a hazardous road location or feature or addresses a highway safety problem, including motorcoach specific projects. The MAP-21 eliminated the 10 percent flex option and expanded HSIP eligibility such that funds can be used for both infrastructure and non-infrastructure highway safety improvement projects that are consistent with the State's SHSP, which can include motorcoach specific programs and projects. Finally, because appropriate EMS response is critical in providing lifesaving interventions at all crash scenes, and more particularly the mass casualties that can result in motorcoach crashes, the FHWA added a Web page to its Safety Web site entitled: Strategic Highway Safety Plans (SHSP) and Emergency Medical Services (EMS). The Web page provides a new resource, Saving Lives Together: The Highway Safety and EMS Connection. This resource was developed through a cooperative effort with FHWA, the National Highway Traffic Safety Administration's Office ofEMS, the National 911 Office, AASHTO, and NASEMSO to encourage and provide resources for collaboration between EMS and highway safety officials through the State's SHSP. The resource includes information about the importance of data and how EMS response, including mass casualty incidents in rural areas, can be addressed through the SHSP process. The resource can be found at http://safety.fhwa.dot.gov/hsip/shsp/ems/connection/index.html. Based on the above-described actions, we respectfully request that Recommendation H-09-7 be reclassified as "Closed-Acceptable Alternate Action."

From: NTSB
To: FHWA
Date: 1/31/2012
Response: The NTSB appreciates the FHWA’s continued collaboration with AASHTO, NASEMSO, the Federal Interagency Committee on EMS, and the National Highway Traffic Safety Administration to develop and implement the recommended risk assessment criteria based on traffic patterns, passenger volume, and bus types. Upon completion, the proposed initiatives should offer the states evaluation tools and guidance to more accurately assess the need for EMS communication and response on rural roads to prioritize safety improvement projects. Regarding the second element of this recommendation, we are aware that the FHWA does not have the authority to affect the states’ selection of HSIP projects for Federal-aid funding. The NTSB would appreciate receiving periodic updates on these efforts as they continue. Pending receipt of this information and completion of the recommended actions, Safety Recommendation H-09-7 remains classified OPEN—ACCEPTABLE ALTERNATE RESPONSE.

From: FHWA
To: NTSB
Date: 10/31/2011
Response: -From Heather Rothenberg, PhD, Office of Safety, Analysis and Evaluation Team: This is a brief update to the initial response to Safety Recommendation H-09-07, currently classified as “Open –Accepted Alternate Response.” The response includes efforts under way under both recommendation H-09-07 made to FHWA, and related recommendation H-09-08 made to the American Association of State Highway and Transportation Officials (AASHTO) and the National Association of State Emergency Medical Services Officials (NASEMSO). The FHWA has opened lines of communication and a partnership with NHTSA to improve the level of participation by EMS officials and stakeholders in the SHSP process within the States. This effort includes regular coordinated communication and efforts with the NHTSA Office of EMS by FHWA, NASEMSO and AASHTO. This coordinated effort has taken place through a project awarded to the RedFlash Group, an EMS marketing and communication firm, to develop marketing and communications materials for both transportation and EMS audiences for the express purpose of bringing the two disciplines together in the SHSP process. FHWA, with NHTSA, AASHTO and NASEMSO participation, is updating the Strategic Highway Safety Plans: A Champion's Guide to Saving Lives to include guidance to elevate the participation of EMS professionals and stakeholders in the SHSP process. Lastly, the FHWA recently awarded a project to develop a Rural Motorcoach Assessment Tool for states to use in evaluating rural roads that are utilized by motorcoaches. The assessment tool will provide a methodology to evaluate these routes and make recommendations for infrastructure safety improvements for inclusion in the State’s SHSP and for possible applicability for HSIP projects. The research will also evaluate EMS communications and response capabilities along those routes in order to offer prioritization of identified safety improvement projects. This effort is the newest and has not been documented in any of our previous updates. Also, note that we are extending the timeline for completion of this work to early 2014. The timeline for the development of the online tool is 2 years which takes us to late 2013. Subsequently, we will provide appropriate updates and then look to close out the project in early 2014.

From: NTSB
To: FHWA
Date: 10/31/2011
Response: On 10/31/2011, CC# 201100414 was combined with 201100260, which included updated information for H-09-007. No letter was sent to the addressee on 10/31/2011.

From: FHWA
To: NTSB
Date: 6/30/2011
Response: CC# 201100260: - From Victor M. Mendez, Administrator: The FHWA submitted its initial response to NTSB on this recommendation in September 2009. In that response, we informed NTSB that we planned to work with the American Association of State Highway Transportation Officials (AASHTO) and the National Association of State Emergency Medical Services Officials (NASEMSO) to explore ways to improve States' collection and use of exposure data on tour and charter motorcoach travel, including identifying ways to leverage existing programs such as the Highway Performance Monitoring System, Strategic Highway Safety Plans (SHSP), Highway Safety Improvement Program (HSIP), and others to address this issue. The FHWA received an official response from NTSB in August 2010. At that time, NTSB classified the recommendation "Open -Acceptable Alternate Response." In November 2009, the FHWA formed a working group to address this issue, which included representatives from FHWA, AASHTO, and NASEMSO. This group has continued to meet on a regular basis. The FHWA, with the assistance of the working group, identified four milestones associated with the completion of efforts to address this recommendation, which is scheduled to be completed in summer 2012. These milestones are: • Develop an Event Response Readiness Assessment Tool and Model Inventory of Emergency Care Elements (MIECE) (December 2011); • Develop Emergency Medical Services (EMS) Marketing and Communications Materials for the Transportation Professionals Project (April 2012); • Update guidance for SHSP development, where appropriate, to include motorcoach associations in the list of partners and add language to the data analysis section that encourages considering high-occupancy vehicles as a risk factor (July 2012); and • Work with the National Highway Traffic Safety Administration (NHTSA) to provide more education on the relationship between SHSP and emergency medical services (ongoing). We expect that the development of the EMS Incident Response Readiness Assessment Tool and MIECE proof of concept document will better enable State and local jurisdictions to respond more efficiently to mass casualty events. The NASEMSO submitted final drafts of these two documents to NHTSA in May 2011. They will be submitted to the Federal Interagency Committee on Emergency Medical Services (FICEMS) at its regular meeting in July 2011. If adopted, the Chair of FICEMS will transmit these two documents (the Institute of Medicine Workshop Summary on the August 2010 Preparedness and Response to a Rural Mass Casualty Incident Workshop (2011» as parts of the final report from FICEMS in response to NTSB Mexican Hat Motor Coach Crash Recommendation H-09-05. The development of the Event Response Readiness Assessment Tool and MIECE should better enable State and local jurisdictions to respond to mass casualty events more efficiently. The NASEMSO and FICEMS have completed a proof of concept on these products. Additionally, the marketing plan associated with the second milestone above will lead to materials to assist transportation professionals in understanding the importance of EMS in highway safety. These marketing materials will also focus on the role of EMS in SHSPs with examples of EMS projects in the HSIP.

From: NTSB
To: FHWA
Date: 8/19/2010
Response: The NTSB is pleased that the FHWA has consulted with AASHTO, NASEMO, and the NTSB regarding the development and implementation of risk assessment criteria based on traffic patterns, passenger volume, and bus types, as recommended. The NTSB also approves of the FHWA's proposed initiatives for completing this element of the recommendation. Regarding the second element of the recommendation, the NTSB notes that the process states use to select Highway Safety Improvement Program projects is aligned with the Statewide Transportation Improvement Program, and the criteria for eligibility of these federal-aid funds are specified by law and cannot be changed at the discretion of the FHWA. Accordingly, Safety Recommendation H-09-07 is classified OPEN – ACCEPTABLE ALTERNATE RESPONSE pending completion and implementation of the recommended criteria for use in assessing the risk of rural travel by large buses.

From: FHWA
To: NTSB
Date: 9/30/2009
Response: Letter Mail Controlled 10/15/2009 4:41:56 PM MC# 2090630 - From Victor M. Mendez, Administrator: This is our initial response to Safety Recommendation H-09-7. On May 29 the National Transportation Safety Board (NTSB) issued this recommendation to the Federal Highway Administration (FHWA) and referenced related recommendation (H-09-8) made to the American Association of State Highway and Transportation Officials (AASHTO) and the National Association of State Emergency Medical Services Officials (NASEMSO). These recommendations address potential safety issues following an investigation of a motorcoach collision that occurred on January 6, 2008, on southbound U.S. Route 163 near Mexican Hat, Utah. The accident resulted in nine fatalities and 43 passenger injuries. Upon concluding its investigation, NTSB pointed out the insufficiency of data collected by the States on motorcoach risk on rural roads which can result in inadequate selection of projects pertaining to motorcoach safety under the FHWA's Highway Safety Improvement Program (HSIP). A main concern is that HSIP projects have historically focused on highway design features and infrastructure characteristics. Also noted was that this accident and the analysis of rural fatal accidents involving charter and tour buses indicate that the risks of rural road travel are not limited to highway design features, but may also be associated with the consequences of a mass casualty event. Furthermore, NTSB concluded that the data requirements under the HSIP make it difficult for States to have the necessary flexibility to use funds for rural road problems effectively. The NTSB agrees that highway safety projects should be data driven, but that rural roads have historically provided little data by which to complete a risk assessment. In developing this response, FHWA has worked and consulted with both AASHTO and NASEMSO and is providing this initial response for Safety Recommendations H-09-7 and H-09-8. To better understand NTSB's intent, staff from the FHWA Office of Safety, along with personnel from AASHTO and NASEMSO convened a joint meeting on July 29 with NTSB to seek clarification of these recommendations. During this meeting NTSB staff expressed appreciation for the opportunity to discuss the underlying intent of this recommendation. They explained that motorcoaches are different than all other forms of surface transportation vehicles because of the large numbers of occupants they carry. If involved in a crash, the potential for mass casualties can impose excessive strain on a State's Emergency Medical Services (EMS) system, resulting in casualties that would not have occurred had appropriate planning measures been in place to assure a rapid and adequate level of response. They also pointed out there is a lack of exposure data for motorcoach travel, particularly in the tour and charter bus industry which vary widely in their frequency and travel routes. In response to NTSB's recommendations, FHWA intends to explore, with AASHTO and NASEMSO, various options to assist the States in addressing these challenges. The initiatives will include the following approaches: - Continue to work with AASHTO and NASEMSO to explore ways to improve the State's collection and use of exposure data on tour and charter motorcoach travel. - Explore the feasibility of collecting exposure data for tour and charter motorcoaches through the Highway Performance Monitoring System. - Examine options to develop additional guidance to encourage and reinforce inclusion of State and local motorcoach industry representatives in the development of State Strategic Highway Safety Plans (SHSP). - Encourage consideration of motorcoach safety issues in the determination of HSIP priorities. - Examine strategies to encourage States, where appropriate, to use the 10 percent flex option for EMS programs that will mitigate response times and increase capacity in responding to motorcoach crashes. The other point discussed with NTSB staff during our July 29 meeting was the portion of the recommendation dealing with FHWA establishing criteria affecting the selection of HSIP projects. During this meeting, FHWA described the authorities it has in administering the Federal-aid HSIP program. Each State is required to have a State HSSP which in turn requires States to develop and implement a State SHSP. Each State's SHSP addresses a myriad of improvements and non-infrastructure related highway safety issues. States also have the flexibility to transfer up to 10 percent of their HSIP funds to non-infrastructure safety projects under Title 23. To date, 10 States have requested and have been approved to use the 10 percent flexibility provision for HSIP funds, resulting in obligations of approximately $19.7 million to non-infrastructure HSIP projects and programs. The process States use to select HSIP projects is aligned with the Statewide Transportation Improvement Program (STIP) and selected projects must advance a State's SHSP. It is through the STIP process that States make decisions on how to use their HSIP funds. The criteria for the eligibility of these funds is specified in law and cannot be changed at the discretion of FHWA. The FHWA has no authority in law to infringe on the rights of the States to select projects for Federal-aid funding, as long as the States comply with all program requirements. The FHWA appreciates the opportunity to work cooperatively with NTSB in addressing the challenges of rural motorcoach travel. For more information, please feel free to contact Mr. Keith D. Williams or Mr. Michael Griffith.