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Safety Recommendation Details

Safety Recommendation H-17-013
Details
Synopsis: About 6:30 a.m. (local time) on Tuesday, November 1, 2016, a 2015 IC 64-passenger school bus was traveling east in the 4000 block of Frederick Avenue in Baltimore, Maryland. The school bus, operated by the motor carrier AAAfordable Transportation, was occupied by a 67-year-old driver and an adult teacher aide. No students were on the bus at the time. After the school bus traveled through the intersection of Frederick Avenue and South Loudon Avenue, it struck the rear of a 2012 Ford Mustang passenger car, which was also traveling east on Frederick Avenue. After striking the Ford Mustang, the school bus continued traveling east on Frederick Avenue, crossed through the center turn lane, and entered the westbound travel lane, where it collided with the left side of a 2005 New Flyer transit bus operated by the Maryland Transit Administration (MTA). The transit bus was occupied by a 33-year-old driver and 13 passengers. As a result of the crash, the drivers of both buses and four transit bus passengers died. Seven transit bus passengers were seriously injured. Two transit bus passengers and the teacher aide on the school bus sustained minor injuries. The driver of the Ford Mustang also sustained minor injuries. Preliminary information suggests that neither bus driver was using a cell phone at the time of the crash. Both bus drivers had been driving for less than 3 hours when the crash occurred. Postcrash mechanical inspections of both buses identified no mechanical defects.
Recommendation: TO BALTIMORE CITY PUBLIC SCHOOLS: Request that the Maryland State Department of Education have an independent and neutral third party conduct a performance audit of your transportation department that includes a review of crash reports and of disqualifying conditions for school bus drivers under Code of Maryland Regulations section 13A.06.07.07. (Urgent)
Original recommendation transmittal letter: PDF
Overall Status: Closed - Acceptable Action
Mode: Highway
Location: Baltimore, MD, United States
Is Reiterated: No
Is Hazmat: No
Is NPRM: No
Accident #: HWY17MH007
Accident Reports: Preliminary Report: Highway HWY17MH007Safety Recommendation Report: Shortcomings of Driver Qualification Processes for Baltimore City Public Schools and of the Disqualified Driver Database for All Maryland School Districts
Report #: HSR-17-02
Accident Date: 11/1/2016
Issue Date: 4/11/2017
Date Closed: 6/21/2018
Addressee(s) and Addressee Status: State of Maryland, City of Baltimore, Public School System (Closed - Acceptable Action)
Keyword(s):

Safety Recommendation History
From: NTSB
To: State of Maryland, City of Baltimore, Public School System
Date: 6/21/2018
Response: From the NTSB Special Investigative Report “Selective Issues in School Bus Transportation Safety: Crashes in Baltimore, Maryland, and Chattanooga, Tennessee.” Report Number SIR-18-02. From section 5.1.4 Safety Recommendations: The NTSB identified deficiencies with the BCPS and MSDE oversight of school bus driver qualifications and operations. To address these failures in oversight, the NTSB issued an early safety recommendation report on the Baltimore crash (NTSB 2017b). Among other deficiencies, the report identified the failure of the BCPS to adequately examine, track, or act in response to reports of previous crashes concerning the bus driver.92 Specifically, in the past 5 years, he had been involved in at least nine crashes or incidents while operating a school bus or personal vehicle. However, only a subset of these events had been reported to the BCPS—and even those were not adequately documented, considered, or reviewed. When each new crash was reported, the BCPS failed to scrutinize the reports of the driver’s prior crashes—and did not recognize or respond to the pattern of documented medical events. Lastly, the BCPS did not take appropriate action to determine the driver’s fitness for duty in response to the October 14, 2011, crash in which he passed out while driving a school bus. Because the BCPS did not adequately document the driver’s previous crashes, BCPS personnel with oversight responsibilities had incomplete information to determine whether he should be disqualified from driving a bus for the school district. These specific shortcomings in BCPS student transportation operating procedures, along with the deficiencies noted in the safety recommendation report, placed BCPS students and the traveling public at risk (NTSB 2017b). The NTSB concludes that though the BCPS was responsible for driver oversight, it failed to address multiple deficiencies and to identify the bus driver as high risk. The BCPS did not perform many of its oversight responsibilities, was inconsistent in interpreting state regulations (COMAR) on what conditions disqualify school bus drivers from employment, and did not comply with federal and state regulations for reviewing or maintaining driver records. Because of concern that the risks posed by unqualified drivers were high, the NTSB issued two safety recommendations to the BCPS (NTSB 2017b): Request that the Maryland State Department of Education have an independent and neutral third party conduct a performance audit of your transportation department that includes a review of crash reports and of disqualifying conditions for school bus drivers under Code of Maryland Regulations section 13A.06.07.07. (H-17-13) (Urgent) As soon as the performance audit referenced in Safety Recommendation H-17-13 is complete, take the corrective actions recommended to improve internal controls and ensure that all school bus drivers meet the qualification standards under Code of Maryland Regulations sections 13A.06.07.06–.07 and that they do not pose any safety risks. (H-17-14) The NTSB also issued one safety recommendation to the MSDE: Review and modify the Code of Maryland Regulations section 13A.06.07.07, “School Vehicle Driver Disqualifying Conditions and Termination,” to clarify the definitions of disqualifying conditions, and to require notification to the Maryland State Department of Education of all drivers who are determined to be not qualified during pre-employment screening. (H-17-15) The BCPS requested that the MSDE have an independent and neutral third party audit the BCPS transportation department. On January 31, 2018, School Bus Contractors, under contract to the MSDE, completed the audit—which concluded that the BCPS had systemic organizational vulnerabilities, deficient internal controls, and a lack of necessary guidance from its governing authority as related to transportation services. These conclusions are consistent with issues discovered during the NTSB investigation of the BCPS and its contractors—and which led the NTSB to issue the urgent recommendation calling for an audit. In addition to not following its own—though lacking—standard operating procedures, the BCPS was found to be out of compliance with several federal and state regulations. The audit further identified instances of medically unqualified drivers, inconsistent and inadequate postcrash actions by the BCPS and its contractors, and inappropriate drug and alcohol testing methodology. The audit recommends immediate corrective actions, emphasizing the absence of BCPS leadership and oversight personnel. Based on the review of this audit and support of its recommendations, the NTSB classifies Safety Recommendation H-17-13 CLOSED—ACCEPTABLE ACTION.

From: NTSB
To: State of Maryland, City of Baltimore, Public School System
Date: 10/2/2017
Response: We note that you requested the MSDE conduct the recommended performance audit. Pending completion of the audit, including a review of crash reports and school bus driver disqualifying conditions under COMAR section 13A.06.07.07, and implementation of the recommended corrective actions, Safety Recommendations H-17-13 and -14 are classified OPEN—ACCEPTABLE RESPONSE.

From: State of Maryland, City of Baltimore, Public School System
To: NTSB
Date: 6/5/2017
Response: -From Dr. Sonja Brookins Santelises, Chief Executive Officer, Baltimore City Public Schools: In compliance with the National Transportation Safety Report Board (NTSB), Recommendation Report, The Baltimore City Public Schools (BCPS) requests that the Maryland State Department of Education (MSDE) select a consultant and/or independent auditor to review and recommend improvements of BCPS's internal controls to ensure that all school bus drivers meet qualification standards under Code of Maryland Regulations 12A.06.07 .06.07. The Office of Pupil Transportation (OPT) is available to assist in any way to ensure that drivers do not pose any safety risks to providing safe, timely and consistent services to students. Thanks in advance for your assistance in this request.

From: NTSB
To: State of Maryland, City of Baltimore, Public School System
Date: 4/11/2017
Response: On March 29, 2017, the NTSB adopted its safety recommendation report concerning the driver qualification processes for BCPS and the disqualified driver database for all Maryland school districts.1 Additional information about the issues and the resulting recommendations may be found in the safety recommendation report, which can be accessed at the NTSB website, under report number NTSB/HSR-17/02. As a result of this safety recommendation report, we issued one new safety recommendation to the Maryland State Department of Education, and the following two recommendations (one urgent) to BCPS.