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Safety Recommendation Details

Safety Recommendation H-10-007
Details
Synopsis: On Friday, January 30, 2009, about 4:06 p.m. mountain standard time, a 2007 Chevrolet/Starcraft 29-passenger medium-size bus, operated by DW Tour and Charter and occupied by the driver and 16 passengers, was traveling northbound in the right lane of U.S. Highway 93, a four-lane divided highway, near Dolan Springs, in Mohave County, Arizona. The bus was on a return trip from Grand Canyon West to Las Vegas, Nevada, after a day-long tour. As the bus approached milepost 28 at a speed of 70 mph,2 it moved to the left and out of its lane of travel. The driver steered sharply back to the right, crossing both northbound lanes and entering the right shoulder. The driver subsequently overcorrected to the left, causing the bus to yaw and cross both northbound lanes. The bus then entered the depressed earthen median and overturned 1.25 times before coming to rest on its right side across both southbound lanes. During the rollover sequence, 15 of the 17 occupants (including the driver) were fully or partially ejected. Seven passengers were killed, and nine passengers and the driver received injuries ranging from minor to serious. At the time of the accident, skies were clear, the temperature was 61° F, and the wind was blowing from the north–northeast at 8 mph.
Recommendation: TO THE NATIONAL HIGHWAY TRAFFIC SAFETY ADMINISTRATION: Require that all buses above 10,000 pounds gross vehicle weight rating be equipped with on-board recording systems that: (1) record vehicle parameters, including, at minimum, lateral acceleration, longitudinal acceleration, vertical acceleration, heading, vehicle speed, engine speed, driver’s seat belt status, braking input, steering input, gear selection, turn signal status (left/right), brake light status (on/off), head/tail light status (on/off), passenger door status (open/closed), emergency door status (open/closed), hazard light status (on/off), brake system status (normal/warning), and flashing red light status (on/off; school buses only); (2) record status of additional seat belts, airbag deployment criteria, airbag deployment time, and airbag deployment energy; (3) record data at a sampling rate sufficient to define vehicle dynamics and be capable of preserving data in the event of a vehicle crash or an electrical power loss; and (4) are mounted to the bus body, not the chassis, to ensure recording of the necessary data to define bus body motion. (This recommendation supersedes Safety Recommendation H-99-53)
Original recommendation transmittal letter: PDF
Overall Status: Open - Unacceptable Response
Mode: Highway
Location: Dolan Springs, AZ, United States
Is Reiterated: Yes
Is Hazmat: No
Is NPRM: No
Accident #: HWY09MH009
Accident Reports: Bus Loss of Control and Rollover
Report #: HAR-10-01
Accident Date: 1/30/2009
Issue Date: 7/8/2010
Date Closed:
Addressee(s) and Addressee Status: NHTSA (Open - Unacceptable Response)
Keyword(s): Recorders

Safety Recommendation History
From: NHTSA
To: NTSB
Date: 3/4/2019
Response: -From Heidi R. King, Deputy Administrator: Safety Recommendations H-99-054 and H-10-007 request that NHTSA develop and implement standards for on-board recording of bus crash data and require that all buses over 10,000 pounds GVWR be equipped with on-board recording systems, respectively. In a letter to the NTSB dated April 12, 2016, the agency explained why it had determined that no further action on Safety Recommendations H-99-054 and H-10-007 was necessary and requested that they be closed. NHTSA decided not to pursue installation requirements for Heavy Vehicle Event Data Recorders (HVEDRs) because our analysis found that many of the heavy vehicle crash characteristics that are important to our understanding of vehicle crash performance are obtainable through traditional crash investigation methods. While HVEDRs could enable collection of data elements that are not available through investigative means (e.g., advanced safety technology activation), requiring such data to be recorded on a HVEDR would, for several reasons, require installation of additional sensor systems. Event data recorders on light vehicles are triggered by the accelerometers that deploy air bags. Because most heavy vehicles are not equipped with air bags, mandating HVEDRs would require the installation of new sensors and NHTSA would need to conduct research to identify appropriate trigger thresholds. NHTSA is concerned about the cost of mandating HVEDRs due to the added expense of installing sensors to collect these additional data and meet the requirements of a HVEDR rulemaking. Current HVEDR installation rates are also very low and fleet-wide installation would add substantial cost. Any decision to regulate the installation of HVEDRs for large buses must be made only after carefully considering the cost of requiring HVEDRs and the potential benefits the additional information would provide. Careful consideration of costs and benefits is especially important when making decisions regarding school buses, where additional costs to school districts could result in reduced fleet size and more students being forced to take less safe means of transportation to and from school. Combined, these challenges present significant difficulties in justifying an HVEDR mandate. NHTSA requests that Safety Recommendations H-99-054 and H-10-007 be closed.

From: NTSB
To: NHTSA
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. The NTSB continues to believe that learning as much as possible about real-world crash dynamics in a school bus collision can be crucial in developing even safer school buses and other student transportation vehicles. NHTSA has not developed standards, nor required the use of HVEDRs, for the commercial passenger vehicles that transport pupils to and from school, school-related activities, and other events—such as school buses, transit buses, or even motorcoaches. These vehicles also transport other passengers for tourism and in commerce, where expectations of safety should parallel those of other modes of commercial passenger transportation. Crash-protected recorders have been required for many years—in some cases, decades—in most large commercial airplanes, marine vessels, and train locomotives. The NTSB concludes that with the continued lack of standards and requirements for HVEDRs, crash data valuable to better understand highway collisions and to improve highway safety continue to go unrecorded. Therefore, the NTSB reiterates Safety Recommendations H-99-54 and H-10-7 to NHTSA.

From: NTSB
To: NHTSA
Date: 11/13/2017
Response: This recommendation is one of four (Safety Recommendations H-99-54, and H-10-7, 14, and -15) that we have issued addressing heavy vehicle EDRs. We are disappointed that you have not developed a requirement to address this important safety issue 7 years after we issued this recommendation. Our 2017–2018 Most Wanted List includes the issue area “Expand Recorder Use to Enhance Safety” because we continue to investigate accidents in which the lack of vehicle data available during the investigation represents a missed opportunity to better understand why and how the crash occurred. We note that you were drafting a white paper explaining your perspective on heavy vehicle EDRs; however, we understand that you did not publish that paper. We believe it would be helpful for our staffs to discuss the current state of EDR use and research. Pending such a discussion, Safety Recommendation H-10-7 remains classified OPEN--UNACCEPTABLE RESPONSE.

From: NHTSA
To: NTSB
Date: 4/12/2016
Response: From Mark Rosekind, Administrator: We provided updates to four of the reiterated Safety Recommendations (H-99-54, H-10-7, H-10-14, and H-10-I5) in a letter dated December 18, 2015. These four Safety Recommendations request that the agency develop and implement performance standards for heavy vehicle event data recorders in trucks and buses over 10,000 pounds. In the December 18 letter, we responded that we intend no further action and requested that these four Safety Recommendations be closed. Safety Recommendation H-10-03 requested that NHTSA's rulemakings include all buses (other than school buses) with GVWRs above 10,000 pounds in order to improve motorcoach roof strength, occupant protection, and window glazing standards. Mid-size buses were discussed in our final rule requiring seat belts on buses 1 and in the proposed rule for bus rollover structural integrity. 2 The agency did not expand applicability of these rulemaking actions to buses with GVWRs between 10,000 and 26,000 pounds because development of a regulation for these buses was not found to be cost beneficial. We intend no further action on this Safety Recommendation, and request that this Safety Recommendation be closed. In summary, we are requesting that Safety Recommendation H-15-04 be classified as "Open Acceptable Response". For the reiterated recommendations H-99-54, H-10-03, H-10-07, H-10-14, and H-10-15, NHTSA intends no further action, and requests that these recommendations be closed.

From: NHTSA
To: NTSB
Date: 12/18/2015
Response: Mark R. Rosekind, Ph.D., Administrator: We intend no further activity for these four Safety Recommendations (H-99-54, H-10-14, H-10-15, and H-10-7) and request they be closed. These four reiterated recommendations request the agency develop and implement performance standards for HVEDRs in trucks and buses over 10,000 pounds. We have studied the issues relating to establishment of performance requirements for HVEDRs and decided not to pursue installation requirements for them. Our analysis found that many of the important heavy vehicle crash characteristics are obtainable through traditional crash investigation methods. For those data elements of most interest that are not available through investigative means (e.g., vehicle acceleration or advanced safety technology activation) recording such data on HVEDR would require installation of additional sensor systems. The added expense of installing sensors to collect these additional data and meet the requirements of a HVEDR rulemaking is likely to remain high for the foreseeable future. Current HVEDR installation rates are also very low and so their fleet-wide installation alone will add cost. All of these factors combined would make justification of a HVEDR mandate difficult through a cost-benefit analysis. We have drafted a white paper outlining these issues and expect to publish that paper this year. A copy of this paper will be provided to NTSB staff when it becomes available.

From: NTSB
To: NHTSA
Date: 12/14/2015
Response: From the Report: Truck-Tractor Semitrailer Median Crossover Collision With Medium-Size Bus on Interstate 35, Davis, Oklahoma,, September 26, 2014, Highway Accident Report NTSB/HAR-15/03 (Washington, DC: National Transportation Safety Board, 2015, Notation 8610B): Dedicated EDRs would not only have been more likely to survive the collision forces and power failure of this crash, but also to yield critical crash data on driver inputs and vehicle dynamics throughout the collision sequence, far beyond the capabilities of a typical EECU. The lack of such data in this collision represents another missed opportunity to better understand the crash why it happened as well as the crash dynamics between the truck-tractor and the bus. Although NHTSA has made progress in developing EDR standards for light vehicles, it has not yet developed standards for nor required the use of EDRs in heavy vehicles, including motorcoaches, school buses, truck-tractor semitrailer combination units, and medium-size buses. The NTSB concludes that because of the continued lack of standards and requirements for EDRs in trucks and buses over 10,000 pounds GVWR, data that are crucial to the improved understanding of crashes, as well as to overall vehicle safety, continue to go unrecorded. Therefore, the NTSB reiterates Safety Recommendations H-99-54 and H-10-7, -14, and -15 to NHTSA.

From: NTSB
To: NHTSA
Date: 8/4/2015
Response: Reiterated in the Highway Accident Report Truck-Tractor Double Trailer Median Crossover Collision with Motorcoach and Postcrash Fire on Interstate 5 in Orland, California on April 10, 2014. HAR-15-01. Notation 8590A. Adopted on July 14, 2015. Issued on August 4, 2015. As the result of an investigation of a bus loss-of-control and rollover in Dolan Springs, Arizona, in January 2009, the NTSB (2010a) recommended that NHTSA: Require that all buses above 10,000 pounds gross vehicle weight rating be equipped with on-board recording systems that: (1) record vehicle parameters, including, at minimum, lateral acceleration, longitudinal acceleration, vertical acceleration, heading, vehicle speed, engine speed, driver’s seat belt status, braking input, steering input, gear selection, turn signal status (left/right), brake light status (on/off), head/tail light status (on/off), passenger door status (open/closed), emergency door status (open/closed), hazard light status (on/off), brake system status (normal/warning), and flashing red light status (on/off; school buses only); (2) record status of additional seat belts, airbag deployment criteria, airbag deployment time, and airbag deployment energy; (3) record data at a sampling rate sufficient to define vehicle dynamics and be capable of preserving data in the event of a vehicle crash or an electrical power loss; and (4) are mounted to the bus body, not the chassis, to ensure recording of the necessary data to define bus body motion. (H-10-7) Upon issuance of Safety Recommendation H-10-7, Safety Recommendation H-99-53 was classified “Closed?Unacceptable Action/Superseded.” Safety Recommendations H-99-54 and H-10-7 are currently classified “Open–Unacceptable Response.” Additionally, in the investigation of a heavy vehicle collision in Miami, Oklahoma, in June 2009, in which there were 10 fatalities, the NTSB (2010b) made the following recommendations to NHTSA: Develop and implement minimum performance standards for event data recorders for trucks with gross vehicle weight ratings over 10,000 pounds that address, at a minimum, the following elements: data parameters to be recorded; data sampling rates; duration of recorded event; standardized or universal data imaging interface; data storage format; and device and data survivability for crush, impact, fluid exposure and immersion, and thermal exposure. The standards should also require that the event data recorder be capable of capturing and preserving data in the case of a power interruption or loss, and of accommodating future requirements and technological advances, such as flashable and/or reprogrammable operating system software and/or firmware updates. (H-10-14) After establishing performance standards for event data recorders for trucks with gross vehicle weight ratings over 10,000 pounds, require that all such vehicles be equipped with event data recorders meeting the standards. (H-10-15) To date, NHTSA has failed to develop standards or require the use of EDRs for heavy vehicles, which include motorcoaches, school buses, or truck-tractor units such as the one involved in the Orland collision. Had the accident truck-tractor and the motorcoach been equipped with dedicated crash EDRs built to minimum performance standards—which include device and data survivability—vital precrash and crash information could have been captured, allowing for a more comprehensive investigation and analysis. Both Safety Recommendations H-10-14 and -15 are currently classified “Open—Unacceptable Response.” 2.8.2 Safety Recommendations The lack of EDR data for the Orland collision represents another missed opportunity to better understand why and how the crash occurred. The NTSB concludes that, due to a lack of standards and requirements for heavy vehicle EDRs, crash data essential to better understanding collisions continue to go unrecorded, thus impeding improvements in highway safety. Therefore, the NTSB reiterates Safety Recommendations H-99-54 and H-10-7, -14, and -15 to NHTSA.

From: NTSB
To: NHTSA
Date: 2/13/2014
Response: CC# 201301266- ANPRM Response to Federal Transit Administration: ANPRM - The National Public Transportation Safety Plan, the Public Transportation Agency Safety Plan, and the Public Transportation Safety Certification Training Program; Transit Asset Management: Although the introduction of the ANPRM states that FTA “intends to focus its initial oversight and enforcement efforts on rail transit systems’ implementation of and compliance with these requirements,” the NTSB would like to provide some additional comments with regard to transit bus safety for FTA’s future planning purposes. As was noted in the ANPRM, the NTSB held an investigative hearing on transit bus safety in March 1998, investigated several transit bus accidents, and issued a Special Investigation Report titled Transit Bus Oversight. The report noted that FTA was unable to identify conditions on buses for the traveling public or resolve any unsafe conditions due to a lack of effective safety oversight and enforcement. In addition, the NTSB questioned the utility of the safety data that was being collected on transit bus safety. Finally, the NTSB was concerned that, at the time, a comprehensive bus safety program was not available to transit agencies outside of APTA’s membership program. Based on the findings of the investigation, the NTSB issued the following safety recommendations to the US Department of Transportation: Develop and implement an oversight program to assess and ensure the safety of transit bus operations that receive Federal funding. (H-98-43) Collect accurate, timely, and sufficient data so that thorough assessments can be made relating to transit bus safety. (H-98-44) Evaluate the collected data, as part of the oversight program, to identify the underlying causes of transit bus accidents that could lead to the identification of safety deficiencies at transit agencies. (H-98-45) Develop, in cooperation with the American Public Transit Association, the Community Transportation Association of America, and the American Association of State Highway and Transportation Officials, a model comprehensive safety program(s) and provide it to all transit agencies. (H-98-46) In response, the FTA-sponsored outreach and research efforts to develop a model program for transit bus safety and security. Subsequently, the recommendations were closed with an acceptable response status by the NTSB. Moving forward, however, these recommendations must not be forgotten as data collection and evaluation is an integral component of any safety management program. It is vital that FTA continue to assess and monitor the safety of transit bus operations, including the collection of accurate, timely, and sufficient data so that thorough assessments can be made relating to transit bus safety. Likewise, it is essential that a program be maintained whereas transit bus accidents are thoroughly investigated to identify the underlying causes of crashes so that safety improvements can be implemented in a timely manner. While the NTSB is encouraged that FTA has developed a well-received bus safety program, we are concerned that the program remains completely voluntary and that FTA is unable to ensure that all bus transit agencies are positively affected. In 2013, the safety of bus operations was highlighted as a safety issue area of concern as part of the NTSB’s Most Wanted List. Over the years, the NTSB has made numerous recommendations to the motorcoach and school bus associations, manufacturers, and regulatory agencies such as the Federal Motor Carrier Safety Administration (FMCSA) and the National Highway Traffic Safety Administration (NHTSA), which the NTSB believes should be considered when establishing a robust oversight program for bus transit operations. These recommendations address safety concerns such as driver distraction, driver fatigue, medical oversight, fire safety, event data recorders, and vehicle safety equipment. FTA should refer to the NTSB safety recommendations database for additional information. The following are examples of some of the NTSB recommendations which should be considered. Event Data Recorders • To FMCSA: Require all heavy commercial vehicles to be equipped with video event recorders that capture data in connection with the driver and the outside environment and roadway in the event of a crash or sudden deceleration event. The device should create recordings that are easily accessible for review when conducting efficiency testing and system-wide performance monitoring programs. (H-10-10) • To NHTSA: Require that all buses above 10,000 pounds gross vehicle weight rating be equipped with on-board recording systems that: (1) record vehicle parameters, including, at minimum, lateral acceleration, longitudinal acceleration, vertical acceleration, heading, vehicle speed, engine speed, driver’s seat belt status, braking input, steering input, gear selection, turn signal status (left/right), brake light status (on/off), head/tail light status (on/off), passenger door status (open/closed), emergency door status (open/closed), hazard light status (on/off), brake system status (normal/warning), and flashing red light status (on/off; school buses only); (2) record status of additional seat belts, airbag deployment criteria, airbag deployment time, and airbag deployment energy; (3) record data at a sampling rate sufficient to define vehicle dynamics and be capable of preserving data in the event of a vehicle crash or an electrical power loss; and (4) are mounted to the bus body, not the chassis, to ensure recording of the necessary data to define bus body motion. (H-10-7)

From: NTSB
To: NHTSA
Date: 2/10/2014
Response: Although we are aware that you have conducted research to gather information about EDRs, we are disappointed that you have not yet implemented a requirement for their use on buses. The need for capturing vehicle data is not new; Safety Recommendation H 10 7 superseded a recommendation issued in a 1999 report because we continue to investigate accidents in which the availability of additional vehicle data would have been helpful in determining the cause and severity of the crash. Accordingly, pending evidence of significant action, such as actual rulemaking, Safety Recommendation H-10-7 remains classified OPEN—UNACCEPTABLE RESPONSE.

From: NTSB
To: NHTSA
Date: 6/7/2011
Response: The NTSB is concerned about NHTSA's continued slow progress in addressing the issue of event data recorders (EDRs). Because it superseded a recommendation from our 1999 bus crashworthiness study, Safety Recommendation H-10-7 was issued with the classification of "Open-Unacceptable Response," the status of the recon1mendation it had superseded. The NTSB understands that NHTSA has been working to develop EDR performance standards with the Society of Automotive Engineers, and we expected to receive NHTSA's decision on rulemaking sometime in 2010. According to NHTSA's 2010-2013 Priority Plan, that rulemaking decision has been delayed until this year. We note that NHTSA has put voluntary standards in place for passenger vehicle EDRs and plans to publish an NPRM to require EDRs for passenger vehicles this year. We encourage NHTSA to move forward promptly with rulemaking on an EDR requirement for all buses above 10,000 pounds GVWR. Pending such action, Safety Recomn1endation H-10-7 remains classified OPEN—UNACCEPTABLE RESPONSE.

From: NHTSA
To: NTSB
Date: 10/7/2010
Response: MC# 201000405 - From David L. Strickland, Administrator: The safety of buses, motorcoaches, and other high occupancy commercial vehicles is a critical component to fulfilling our mission to prevent deaths and injuries on the nation's roadways. Because these vehicles serve as public transportation systems, there is an expectation that the highest levels of safety stringency be applied, especially since these vehicles often transport our most vulnerable populations, including children and the elderly. NHTSA's Vehicle Safety Rulemaking and Research Priority Plan 2009-2011 (Docket No. NHTSA-2009-0108) delineates our near-term actions in addressing these populations and vehicle types, and references related NTSB recommendations where appropriate. We are currently in the final process of publishing an update to that Plan for the time period 2010-2013. On August 18 we published a Notice of Proposed Rulemaking (NPRM) that proposes to address issues related to high occupancy vehicle Federal motor vehicle safety standards (FMVSS), motorcoach definition, and occupant crash protection (see 75 FR 50958, Docket No. NHTSA 2010-0112). The comment period for this NPRM closes on October 18. We highly encourage NTSB to submit comments on this proposed rule so we can incorporate these in our deliberations toward developing a final rule. Additional public documents that detail our vision, plans, and approach to high occupancy vehicle safety include our 2007 "NHTSA's Approach to Motorcoach Safety" (Docket No. NHTSA-2007-28793) and the DOT's 2009 Motorcoach Safety Action Plan (HS 811 177). Recommendation H-10-07 directs NHTSA to require on-board recording systems for buses with a GVWR above 10,000 lb, and specifies several parameters and requirements that NTSB deems critical for the proper functionality and data integrity of such devices. As the NTSB is aware, we have been working for several years with the Society of Automotive Engineers (SAE) Truck and Bus Committee on the development of SAE Recommended Practice J2728, "Heavy Vehicle Event Data Recorder (HVEDR) - Base Standard. This standard is being developed to define specifications and functional requirements for HVEDRs for the reliable and accurate recording of the crash parameters that are relevant to heavy vehicles, which are considerably different from those for light passenger vehicles. We agree with the intent of this Recommendation that the presence of EDRs on heavy vehicles would enhance the science that can applied to, and data that can be elicited from, the analysis of future crash events involving heavy vehicles. The 2009-2011 Priority Plan indicated that the agency intends to make a decision on developing performance requirements for HVEDRs in 2010. We are on schedule to meet that milestone as planned, and will apprise the NTSB as to the decision and next steps at the appropriate time. As always, NHTSA appreciates the NTSB's efforts toward our shared commitment to improving transportation safety, and welcomes the opportunity to articulate how the NTSB's recommendations are being implemented within NHTSA's overall strategic vision. We respectfully request that Recommendations H-l 0-01 through -07 be classified as "Open, Acceptable Response", based on our current efforts, and the future initiatives outlined in the "DOT Motorcoach Safety Plan", "NHTSA's Approach to Motorcoach Safety", and our Priority Plan. If you have any questions, or require additional information, please contact me, or Ms. Melanie O'Donnell, our NTSB liaison in the Office of Strategic Planning, at 202-366-0689 or by email at rnelanie.odonnell@dot.gov.

From: NTSB
To: NHTSA
Date: 7/8/2010
Response: From the safety recommendation letter issuing Safety Recommendations H-10-1 through -7 issued on July 8, 2010 in response to the bus accident near Dolan Springs, AZ on January 30, 2009. Safety Recommendation H-99-53 specifies that EDRs be required for school buses and motorcoaches. However, as illustrated by the Dolan Springs accident, EDR data would also be useful in the reconstruction of preaccident events and crash dynamics for medium-size buses. Because SAE RP J2728 is designed to address the application of EDRs in vehicles over 10,000 pounds GVWR, it should be possible for NHTSA to include all buses above 10,000 pounds GVWR in any regulatory requirements based on RP J2728. The NTSB concludes that having EDRs on all buses above 10,000 pounds GVWR would greatly increase the understanding of crash causation and be helpful in further establishing design requirements for crashworthiness and occupant protection systems. As a result, the NTSB recommends that NHTSA require that all buses above 10,000 pounds be equipped with on-board recording systems that: (1) record vehicle parameters, including, at minimum, lateral acceleration, longitudinal acceleration, vertical acceleration, heading, vehicle speed, engine speed, driver’s seat belt status, braking input, steering input, gear selection, turn signal status (left/right), brake light status (on/off), head/tail light status (on/off), passenger door status (open/closed), emergency door status (open/closed), hazard light status (on/off), brake system status (normal/warning), and flashing red light status (on/off; school buses only); (2) record status of additional seat belts, airbag deployment criteria, airbag deployment time, and airbag deployment energy; (3) record data at a sampling rate sufficient to define vehicle dynamics and be capable of preserving data in the event of a vehicle crash or an electrical power loss; and (4) are mounted to the bus body, not the chassis, to ensure recording of the necessary data to define bus body motion. (H-10-007) This recommendation replaces Safety Recommendation H-99-53, which the NTSB classifies Closed-- Unacceptable Action/ Superseded. H-10-7 supersedes Safety Recommendation H-99-53 and is classified "OPEN -- UNACCEPTABLE RESPONSE."