The National Transportation Safety Board today determined that the probable cause of the fatal crash of a van transporting children from a child care center in Memphis, Tennessee, was the absence of oversight by the center's owners and the driver's inability to maintain control of his vehicle because he fell asleep, quite likely due to an undiagnosed sleep disorder. The drivers' use of marijuana may also have played a role in the accident, the Board said.
"Our investigation uncovered a string of failures that led to this tragic accident," said NTSB Chairman Ellen Engleman- Conners. "It demonstrates once again that everyone in the transportation safety chain must do their part to avoid placing our children in harms way."
The accident occurred on April 4, 2002, when a 15-passenger Ford E-350 van transporting six children to school on Interstate 240 in Memphis drifted off the right side of the roadway, overrode the guardrail and struck a bridge abutment. The driver was ejected through the windshield and sustained fatal injuries. Four of the children also were killed, and two were seriously injured.
Safety Board investigators found no mechanical defects on the van that would have contributed to the accident. The weather was clear and the roadway dry. Post-accident toxicological tests indicate that the driver consumed marijuana on the morning of the accident and was under the influence of the drug at the time of the crash. Investigators also found that the driver had a history of difficulty maintaining wakefulness, probably reflecting a condition of sleep apnea or another undiagnosed sleep disorder. This combined with witness reports of a lack of brake light illumination and the drifting of the van off the roadway is consistent with a driver who has fallen asleep.
The Board stated that because the owners of the child care center did not comply with state law, and the Tennessee Department of Human Services did not provide adequate oversight, the van driver was able to transport children even though he had not had a background check or medical examination. Had drug testing been conducted, the Board said, the driver's drug use would likely have been detected and he may have been prohibited from transporting children.
Further, the Board noted that had the center's owners used a vehicle built to school bus standards, rather than a 15- passenger van, and had appropriate restraints (seatbelts, booster seats) been used, the injuries from this accident might have been less severe.
The Board also identified flaws in the design of the guardrail at the accident site that allowed the van to become trapped behind the guardrail and strike the bridge abutment.
As a result of the accident, the Board made recommendations to the agencies in the 50 states and the District of Columbia that oversee child care transportation calling for the use of vehicles built to school bus standards, regular vehicle maintenance and inspection programs, a requirement that occupants wear age-appropriate restraints at all times, and background checks, medical examinations and drug testing to determine driver fitness. Recommendations also were made regarding improvements in roadside guardrails.
A synopsis of the accident investigation report, including the findings, probable cause, and safety recommendations can be found on the Publications page of the Board's web site, http://www.ntsb.gov. The complete report will be available in about six weeks.