You may be trying to access this site from a secured browser on the server. Please enable scripts and reload this page.
Turn on more accessible mode
Turn off more accessible mode
Skip Ribbon Commands
Skip to main content
Top Link Bar
NEWS & EVENTS
Speeches & Testimony
Most Wanted List
The Investigative Process
Data & Stats
General Aviation Safety
Administrative Law Judges
Strategic Plans & Reports
Safety Recommendation Details
The Investigative Process
Data & Stats
General Aviation Safety
On March 12, 2011, about 5:38 a.m., a 1999 Prevost 56-passenger motorcoach, operated by World Wide Travel of Greater New York, headquartered in Brooklyn, was traveling southbound on Interstate 95, en route from the Mohegan Sun Casino in Uncasville, Connecticut, to New York City, and carrying 32 passengers. While in the vicinity of mile marker 3.2, the motorcoach departed from the travel lanes to the right, driving over the rumble strips on the right shoulder edge. The motorcoach then crossed over the 10-foot-wide paved shoulder and struck a strong-post W-beam guardrail, traveling about 480 feet alongside and on the guardrail, before finally overturning 90° onto its right side and flattening the guardrail. The front of the vehicle subsequently collided with a vertical highway signpost consisting of two vertical 8-inch-diameter steel tubular poles linked by cross-beam diagonal metal supports. The front roof also collided with a steel electrical box mounted to the sign support structure. After the motorcoach struck the support structure and electrical box, the two poles entered the passenger compartment along the base of the passenger windows as the vehicle slid forward. The impact resulted in the roof panel being torn from the bus body for almost the entire length of the bus. As a result of this accident, 15 passengers were killed, 17 passengers received serious-to-minor injuries, and the bus driver received minor injuries.
TO THE FEDERAL MOTOR CARRIER SAFETY ADMINISTRATION: Include in the safety fitness rating rulemaking for the new Compliance, Safety, Accountability initiative a structured process, such as the Safety Management Cycle, to be used by Federal Motor Carrier Safety Administration investigators and their state Motor Carrier Safety Assistance Program agents, as an audit tool for investigators to (1) identify the root cause of safety risks found during compliance reviews, and (2) deliver constructive guidance to motor carriers to ensure the promotion of safety management.
Original recommendation transmittal letter:
Closed - Acceptable Alternate Action
New York City, NY, United States
Motorcoach Run-Off-the-Road and Collision With Vertical Highway Signpost, Interstate 95 Southbound
Addressee(s) and Addressee Status:
FMCSA (Closed - Acceptable Alternate Action)
Safety Recommendation History
We commend your efforts to build on the Independent Review Team’s recommendations to move forward with improving your compliance review process, rather than wait for the SFD final rule. We note that you are using both the safety management cycle and enhanced investigative techniques to collaborate with motor carriers and share safety information to improve their compliance. In addition, you implemented quality review tools and a peer review process, including compliance reviews and enforcement actions, to evaluate and improve field operation quality, and you consolidated your systems, policies, and informational materials to improve ease of access. The combined effect of these efforts, based on internal policies and procedures, represents an acceptable alternate means of addressing Safety Recommendation H 12-18, which is classified CLOSED--ACCEPTABLE ALTERNATE ACTION.
-From Michael Jordan, Strategic Planning and Program Evaluation Division, Federal Motor Carrier Safety Administration: Report: Investigation - New York City, New York (2011-03-12) Current Classification: Open - Acceptable Response Requested Classification: Closed • FMCSA has implemented an approach that meets the intent of this safety recommendation, absent rulemaking, that trained safety investigators (SI) and State Partners to conduct compliance reviews utilizing not only the Safety Management Cycle (SMC) but also Enhanced Investigative Techniques (EIT). By using both the SMC & EIT throughout the investigative process, investigators identify not only violations but the root cause of those violations (EIT) and work collaboratively with the motor carrier to identify remedies to safety management breakdowns that are causing violations. By using both of these processes, the investigator is able to provide education to the motor carrier as well as sharing safety information to assist the motor carrier with its compliance efforts. These new procedures were recommended by an Independent Review Team (IRT) which was convened in response to a previous NTSB recommendation, which was subsequently classified “Closed – Exceeded Expectations” by the NTSB. The IRT report published on July 15, 2014, is available online at https://www.fmcsa.dot.gov/sites/fmcsa.dot.gov/files/docs/FINAL%20REPORT%20-%20IRT_July%2015.pdf and included a recommendation (Recommendation 2.6.1) that FMCSA should: o “Establish routine quality reviews of CR processes and outcomes by Division Administrators in each state such as those applied during 2013 Quick Strike; o “Create a mechanism by which practices and outcomes across divisions and regions are reviewed to identify best practices, problem areas, and patterns that indicate training may be needed; and, o “Perform consistent, detailed, headquarters evaluations of enforcement effectiveness—by enforcement tool, by division, and by case/investigator; use the analysis to provide regular feedback to divisions and regions about their effectiveness and to inform Agency adjustments to policies and expectations.” • FMCSA has implemented quality review tools for its compliance reviews and enforcement actions and a peer review process to evaluate and improve the quality of field operations. These changes have not only enhanced the timeliness and quality of compliance reviews but has provided FMCSA with the necessary data to identify training needs on not only an individual level, but also a Divisional, Service Center or National level. • FMCSA has completed several efforts to further enhance FMCSA’s management of compliance reviews to include the following: o Developed, piloted, and implemented two essential quality improvement monitoring efforts which are in effect nationwide — Quality Assurance (QA) Peer Review and Quality Review Tools (QRT). o Completed more than 1,400 Quality Investigation Assessments and 1,300 Enforcement Case Assessment Skills Evaluations since launching the automated QRT system in February 2017. The system has helped staff better identify areas to focus training, policy, and outreach to motor carriers. o Developed the Activity Center for Enforcement (ACE) which provides online tools to enhance the ability of FMCSA field personnel to identify and manage the motor carrier population. ACE provides investigators and management staff a “one stop” location for accessing FMCSA data systems and provides access to policies and educational materials used in the investigative process. • FMCSA requests NTSB close safety recommendation H-12-018.
We support the FMCSA’s efforts to incorporate use of the SMC into all investigations and to encourage its voluntary use by motor carriers to identify and address safety risks. In addition, we encourage the FMCSA to include the SMC in the safety fitness determination NPRM, and we look forward to reviewing the NPRM when it is released later this year. In the meantime, Safety Recommendation H-12-18 is classified OPEN—ACCEPTABLE RESPONSE.
-From Anne S. Ferro, Administrator: Under FMCSA's data-driven Compliance, Safety, Accountability (CSA) enforcement program, motorcoach and other commercial passenger carriers with safety problems in even one of seven performance areas are immediately targeted for safety interventions-ranging from warning letters, on-site safety compliance reviews, federal fines, and out-of-service orders. In September 20 II, FMCSA integrated the Safety Management Cycle (SMC) component of CSA into all investigations. The SMC is a holistic systems view of the management processes and improvement practices a motor carrier may implement to assist in compliance with FMCSA's regulations. It allows investigators to systematically identify truck and bus companies' underlying safety problems. The SMC enables investigators to recommend more effective remedies to help carriers improve their safety performance. All Federal and State investigators have been trained on the new investigative process. The SMC is not a mandated requirement for the motor carrier. It is however, an educational tool that assists the motor carrier in identifying the root cause of safety risks. It allows the investigator to deliver constructive guidance to motor carriers and promotes strong safety management. Nationwide rollout of SMC as a tool for all its Federal investigators and Motor Carrier Safety Assistance Program personnel was completed in the fall of 20l1. This included policy development and implementation, and the training for all field staff. As a result, all focused and comprehensive investigations now include the application of the SMC. The SMC is addressed in the industry presentation located on the CSA website at http://csa.fmcsa.dot.gov/resources.aspx. Based on the information provided, FMCSA believes that it has fully addressed Safety Recommendation H-12-18 and respectfully requests that NTSB classify this recommendation as "Closed-Acceptable."
Strategic Plan, Performance & Accountability Reports & More
Directions to Conference Center
Web Policies & Notices
Annual Review of Aircraft