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Safety Recommendation Details

Safety Recommendation H-18-018
Synopsis: In November 2016, the NTSB began the investigation of two crashes involving school buses. Each crash was initiated when the driver lost control of the bus. In the November 1 crash in Baltimore, Maryland, the driver was epileptic and suffered a seizure. In the November 21 crash in Chattanooga, Tennessee, the driver was speeding while using a cell phone and ran off the road. In both cases, the school bus operators were private for-hire motor carriers. Although the specific safety issues differed, the crashes shared one common factor: poor driver oversight by both the school districts and the contracted motor carriers, which resulted in unsafe operation of the school buses. Between the two crashes, 12 people died and 37 were injured. The crash investigations focused on the following safety issues: school districts’ lack of oversight of student transportation providers; poor management of unsafe school bus drivers by the motor carriers and school districts; medically unfit school bus drivers; commercial driver license fraud; occupant protection in large school buses; and the benefits of electronic stability control, automatic emergency braking, and event data recorders. The NTSB made safety recommendations to the Federal Motor Carrier Safety Administration; the National Highway Traffic Safety Administration (NHTSA); the states of Florida, Louisiana, New Jersey, and New York; 42 states, the District of Columbia, and the territory of Puerto Rico—which lack requirements for lap/shoulder belts on large school buses; the state of Maryland; the Maryland Department of Education; the Maryland Motor Vehicle Administration; five school bus transportation associations; National Express LLC; seven school bus manufacturers; five electronic health record companies; and Concentra, Inc. The report also reiterates four recommendations to NHTSA and reclassifies a recommendation to the Baltimore City Public Schools.
Recommendation: TO NATIONAL EXPRESS LLC: Use industry best practices to establish resolution accountability for serious or recurring safety violations, to include effective remediation of unsafe driver behavior.
Original recommendation transmittal letter: PDF
Overall Status: Closed - Acceptable Action
Mode: Highway
Location: Chattanooga, TN, United States
Is Reiterated: No
Is Hazmat: No
Accident #: HWY17MH009
Accident Reports: Preliminary Report: HIGHWAY - HWY17MH009
Report #: SIR-18-02
Accident Date: 11/21/2016
Issue Date: 6/21/2018
Date Closed: 12/7/2018
Addressee(s) and Addressee Status: National Express LLC (Closed - Acceptable Action)

Safety Recommendation History
From: NTSB
To: National Express LLC
Date: 12/7/2018
Response: We are pleased that you implemented the recommended complaint resolution system and have established training and monitoring systems to identify and resolve safety violations. In addition, your decision to install cameras in all fleet vehicles shows your commitment to developing a comprehensive safety management system for driver oversight and remediation of unsafe behavior throughout your fleet. We commend your prompt action to embrace the intent of our recommendations and invest in company-wide procedures to improve safety across all your operations. These actions satisfy Safety Recommendations H-18-17 and -18, which are classified CLOSED--ACCEPTABLE ACTION.

From: National Express LLC
Date: 9/20/2018
Response: -From Robert Ramsdell, Chief Safety Officer, NELLC: National Express is committed to policies and standard operating procedures that support safety. We comply with all state and federal laws related to commercial drivers in general as well as those specific to school bus drivers. To ensure our managers are prepared to address safety violations or unsafe driver behavior, during June and July of 2018, as the Chief Safety Officer, I personally provided training to all general managers on the importance of driver management and oversight, including the consistent application of all safety policies and procedures in live, in-person training sessions or via WebEx. The primary message of the training was that nothing we do is more important than deciding who drives our vehicles. Specifically, managers were trained on the characteristics that make a good driver and the tools they have at their disposal to make that determination, including our driver qualification standards, the rules in our employee handbook, speed reports, information from our feedback management system BusReport, and events from DriveCam, our smart camera system. In addition to this live training for general managers, in August 2018 this training was adapted into an eLearning module titled “Who’s Driving Your Bus? Driver Oversight and Management” and assigned to all general managers to reinforce the initial training as well as to an expanded group that included all operations supervisors, safety and training supervisors and dispatchers to ensure everyone understands what is expected when it comes to driver performance management. The eLearning module includes a test that must be passed with a score of 90% or better to ensure participants fully comprehend the material. We also developed an eLearning module titled “The Employee Handbook as a Tool for Managing Performance; Managing Unsafe Behaviors” that was assigned to all managers, supervisors and dispatchers throughout the organization in August 2018. This training covers the responsibility of managers to consistently manage behavior based upon the policies and procedures contained in the employee handbook. It identifies key points regarding safety and operational procedures in the handbook that relate to employee performance and trains managers on how to determine, implement, and document appropriate action when performance does not meet expectations, including when to take an employee off the road following violation of safety policies or procedures. It also reinforces our belief that the general managers’ primary responsibility is to ensure all drivers are safe and fit for duty. The training covers the sources of input for managing performance, including observations, complaints, smart camera events, and speed, pre-trip, and post-trip data available through our GPS system. It provides guidance on investigation and validation of the input, and finally takes managers through what is expected when it comes to corrective action. It contains scenarios that must be addressed by correctly applying the policies and procedures contained in the employee handbook; topics include safety meeting attendance, cell phone events, smart camera events, complaints, unsafe driving, speeding, and post-accident procedures, including those events that in and of themselves, must result in termination of employment under our policy. The training ends with a test that must be passed with a score of 90% or better to ensure participants fully comprehend the material. In addition to the training referenced above to prepare managers for managing safety performance of our drivers, in September of 2018 we developed and launched a Driver Safety Scorecard to give managers a tool for identifying drivers whose overall performance in a few key areas may indicate they need additional coaching, training, or more frequent check-ups to ensure they are safe to operate our vehicles beyond that which they received when the individual events occurred. The behaviors included in the Driver Safety Scorecard include preventable accidents in the past 24 months, safety complaints in the past 90 days, minutes speeding in the past 60 days, smart-camera events in the past 60 days, and tenure. The scorecard is housed in DOMO, a cloud based system for sharing data that provides visibility to all levels of management. Drivers identified as being in need of additional coaching, training, or monitoring are brought in for a coaching session where actions to improve performance are identified. The review of Driver Safety Scorecard and subsequent coaching sessions occur monthly and are tracked centrally to ensure accountability at all levels. In addition to the training referenced above, in 2017 we implemented Beacon, an electronic driver qualification file (DQF) system that provides centralized visibility to DQF compliance. To ensure drivers do not have any activity on their motor vehicle record that would disqualify them from driving for us, we are in the process of registering all of our drivers with Samba Safety, a vendor that provides automatic updates anytime a driver has a violation, suspension or revocation of their drivers’ license. All of our drivers will be registered in this system by October 1, 2018. To provide our managers and supervisors with a means to identify unsafe driving behaviors, our implementation of DriveCam, a smart-camera system continues with over 9,000 vehicles installed and an additional 9,000 scheduled to be installed in the Q4 of 2018. The balance of our fleet will be installed in 2019. This system enables us to identify and address unsafe driving behaviors prior to an accident occurring and is integrated into our driver coaching tools and scorecard. As these actions demonstrate, National Express LLC is committed to safety and improving the execution of our safety policies and procedures in all of our operations.

From: NTSB
To: National Express LLC
Date: 6/21/2018
Response: The National Transportation Safety Board (NTSB) is an independent federal agency charged by Congress with investigating every civil aviation accident in the United States and significant accidents in other modes of transportation—railroad, highway, marine, and pipeline. We determine the probable cause of the accidents and issue safety recommendations aimed at preventing future accidents. In addition, we carry out special studies concerning transportation safety and coordinate the resources of the federal government and other organizations to provide assistance to victims and their family members affected by major transportation disasters. On May 22, 2018, the NTSB adopted its report Selective Issues in School Bus Transportation Safety: Crashes in Baltimore, Maryland, and Chattanooga, Tennessee, NTSB/SIR-18/02. The details of these investigations and the resulting safety recommendations may be found in the attached report, which can also be accessed at Among the safety recommendations are two new recommendation issued to National Express LLC, which can be found on page 77 of the report. The NTSB is vitally interested in these recommendations because they are designed to prevent accidents and save lives. We would appreciate a response within 90 days, detailing the actions you have taken or intend to take to implement them. When replying, please refer to the safety recommendations by number. We encourage you to submit your response to If it exceeds 10 megabytes, including attachments, please e-mail us at the same address for instructions. Please do not submit both an electronic copy and a hard copy of the same response.