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Safety Recommendation Details

Safety Recommendation H-10-011
Synopsis: On June 26, 2009, a multivehicle accident occurred on Interstate 44 (I-44) near Miami, Oklahoma, shortly after a minor accident in the same vicinity occurred. The minor accident took place about 1:13 p.m., when a 2001 Ford Focus traveling eastbound at milepost 321.7 on I-44 drifted into a truck-tractor semitrailer parked on the right shoulder. After the Focus sideswiped the semitrailer, the car’s driver overcorrected to the left, lost control, and struck the concrete center median barrier. The Focus came to rest in the roadway, blocking the left eastbound lane. As the trailing traffic began to slow and stop, it formed a queue. Several motorists exited their vehicles and began to push the disabled Focus to the right shoulder. The queue of stopped vehicles and approaching but slowing vehicles extended back from the accident site approximately 1,500 feet to about milepost 321.5. Meanwhile, about 1:19 p.m., a 76-year-old truck driver operating a 2008 Volvo truck-tractor in combination with an empty 2009 Great Dane refrigerated semitrailer was traveling eastbound in the outside (right) lane of I-44 at approximately 69 mph. (The posted speed limit was 75 mph.) The truck driver did not react to the queue of slowing and stopped vehicles and collided with the rear of a 2003 Land Rover sport utility vehicle (SUV). As both vehicles moved forward, the Land Rover struck a 2003 Hyundai Sonata and then departed the right lane and shoulder, coming to rest off the roadway. The Volvo continued forward, struck and overrode the Hyundai Sonata, struck and overrode a 2004 Kia Spectra, and then struck the rear of a 2000 Ford Windstar minivan. The Volvo overrode a portion of the Windstar while pushing it into the rear of a livestock trailer being towed by a 2004 Ford F350 pickup truck. The Ford pickup truck was pushed forward and struck a 2008 Chevrolet Tahoe SUV. The Volvo combination unit came to rest approximately 270 feet past the point where it initially struck the Land Rover. As a result of the Volvo combination unit’s striking the slowed and stopped vehicle queue on I-44, 10 passenger vehicle occupants died, 5 received minor-to-serious injuries, and the driver of the Volvo combination unit was seriously injured.1 The National Transportation Safety Board determined that the probable cause of this accident was the Volvo truck driver’s fatigue, caused by the combined effects of acute sleep loss, circadian disruption associated with his shift work schedule, and mild sleep apnea, which resulted in the driver’s failure to react to slowing and stopped traffic ahead by applying the brakes or performing any evasive maneuver to avoid colliding with the traffic queue. Contributing to the severity of the accident were the Volvo truck-tractor combination unit’s high impact speed and its structural incompatibility with the passenger vehicles.
Recommendation: TO THE FEDERAL MOTOR CARRIER SAFETY ADMINISTRATION: Require motor carriers to review and use video event recorder information in conjunction with other performance data to verify that driver actions are in accordance with company and regulatory rules and procedures essential to safety.
Original recommendation transmittal letter: PDF
Overall Status: Closed - Unacceptable Action
Mode: Highway
Location: Miami, OK, United States
Is Reiterated: Yes
Is Hazmat: No
Accident #: HWY09MH015
Accident Reports: Truck-Tractor Semitrailer Rear-End Collision Into Passenger Vehicles on Interstate 44
Report #: HAR-10-02
Accident Date: 6/26/2009
Issue Date: 10/21/2010
Date Closed: 6/3/2019
Addressee(s) and Addressee Status: FMCSA (Closed - Unacceptable Action)
Keyword(s): Recorders

Safety Recommendation History
From: NTSB
Date: 6/3/2019
Response: Our intent in issuing these recommendations was to establish a requirement for all heavy commercial vehicles to be equipped with VERs and for all active interstate motor carriers to be required to use the captured VER data to verify driver safety performance. We note that you have taken some steps toward addressing these recommendations, encouraging motor carriers to implement VERs in their fleet and publishing a final rule in 2016 to allow installation of windshield-mounted technologies in the swept area; however, we are disappointed that you continue to promote a voluntary adoption policy that does not satisfy the recommended actions. Because of the age of these recommendations and the fact that you intend to take no further action to implement the recommended mandates, Safety Recommendations H-10 10 and -11 are classified CLOSED--UNACCEPTABLE ACTION.

Date: 9/6/2017
Response: -From Michael Jordan, Strategic Planning and Program Evaluation Division, Federal Motor Carrier Safety Administration: Report: Investigation - Miami, Oklahoma (2009-06-26) Current Classification: Open – Acceptable Alternate Response Requested Classification: Closed • Please see the written update provided above for safety recommendation H-10-010. • FMCSA plans no further action via rulemaking that would require motor carriers to review and use video event recorder information to verify that driver actions are in accordance with company and regulatory rules and procedures essential to safety. • FMCSA requests NTSB close safety recommendation H-10-011.

From: NTSB
Date: 7/6/2016
Response: We appreciate your change of direction in response to these recommendations. We further look forward to reviewing your proposed rulemaking allowing motor carriers to mount video event recorders within the wiper-swept area of the windshield, once the rule is published. When the rule is finalized and paired with the Beyond Compliance program incentives to encourage early adoption of video monitoring safety programs and video event recorder technologies by a majority of motor carriers, the combined effect of these efforts could result in an acceptable alternate means of satisfying the intent of Safety Recommendations H-10-10 and -11. In the meantime, these recommendations are classified OPEN—ACCEPTABLE ALTERNATE RESPONSE.

Date: 12/23/2015
Response: -From Michael Jordan, Management and Program Analyst, Strategic Planning and Program Evaluation Division, Federal Motor Carrier Safety Administration: • 393.60(e) requires devices mounted at the top of the windshield to be located (1) not more than 6 inches below the top of the windshield, (2) outside the swept area of the windshield wipers, and (3) outside the driver’s sight lines to the road and highway signs and signals. • However, for optimal effectiveness, the forward lens of video event recorders must be mounted within the swept area of the windshield wipers for a clear view in inclement weather. • Since April 2009, FMCSA has allowed (via a temporary exemption that was subsequently renewed in 2011, 2013, and 2015) video event recorders to be used in CMVs provided they are mounted not more than 2 inches below the upper edge of the area swept by the windshield wipers, and outside the driver’s sight lines to the road and highway signs and signals. The current exemption expires on April 16, 2017. • FMCSA is not aware of any degradation in safety due to the use of video event recorders, mounted within the swept area of the windshield in accordance with the provisions of the temporary exemption. • Based on the above, FMCSA plans to initiate a rulemaking to amend 393.60(e) to permit certain devices to be mounted within the swept area of the windshield of CMVs. Advocates for Highway and Auto Safety and others have already indicated support for such an amendment. FMCSA expects to publish an NPRM on this issue in early 2016, depending on other Agency and end-of-Administration priorities. • The Agency believes that amending 393.60(e) to expressly allow devices such as video event recorders to be mounted in the swept area of the windshield will prompt more motor carriers to voluntarily adopt such technology in their vehicles. • In addition to the above, FMCSA published a Federal Register notice on April 23, 2015, requesting comments and input regarding the potential development of a Beyond Compliance program that would: o Identify new safety technologies and safety management practices that the Agency wants to incentivize for early adoption; o Determine the incentives for voluntary adoption; and o Monitor ongoing compliance of early adoption. • FMCSA is in the process of evaluating (1) comments received in response to the April notice, and (2) recommendations from the Motor Carrier Safety Advisory Committee (MCSAC), on the potential benefits and feasibility of a Beyond Compliance program. The MCSAC specifically included video event recorders as a potential safety technology for inclusion in a Beyond Compliance program. FMCSA requests that NTSB reclassify Safety Recommendation H-10-011 as “Open - Acceptable Alternate Response.”

From: NTSB
Date: 2/8/2012
Response: Notation 8245A: On Thursday morning, August 5, 2010, in Gray Summit, Missouri, traffic slowed in the approach to an active work zone on eastbound Interstate 44 (1-44), as motor vehicles merged from the closed left lane to the right lane. A 2007 Volvo truck-tractor with no trailer was traveling eastbound in the right lane and had slowed or stopped behind traffic. About 10: 11 a.m. central daylight time, a 2007 GMC Sierra extended cab pickup truck merged from the left to the right lane and struck the rear of the Volvo tractor. This collision was the first in a series of three. A convoy of two school buses from St. James High School, St. James, Missouri, was traveling eastbound in the right lane of 1-44, approaching the slowed traffic and the collision ahead. Their destination was the Six Flags St. Louis amusement park in Eureka, Missouri. The lead bus was a 71-passenger school bus, occupied by 23 passengers. Following closely behind the lead bus was a 72-passenger school bus, occupied by 31 passengers. Seconds after the lead bus passed a motorcoach that had pulled over and stopped on the shoulder, it struck the rear of the GMC pickup. This collision-the second in the series-pushed the pickup forward, overturning it onto the back of the Volvo tractor. The front of the lead bus was ramped upward, as it came to rest on top of the GMC pickup and the Volvo tractor. Moments later, the following school bus struck the right rear of the lead bus. As a result of this accident sequence, the driver of the GMC pickup and one passenger seated in the rear of the lead school bus were killed. A total of35 passengers from both buses, the 2 bus drivers, and the driver of the Volvo tractor received injuries ranging from minor to serious. Eighteen people were uninjured. The National Transportation Safety Board (NTSB) determined that the probable cause of the initial Gray Summit collision was distraction, likely due to a text messaging conversation being conducted by the GMC pickup driver, which resulted in his failure to notice and react to a Volvo tractor that had slowed or stopped in response to a queue that had developed in a work zone. The second collision, between the lead school bus and the GMC pickup, was the result of the bus driver's inattention to the forward roadway due to excessive focus on a motorcoach parked on the shoulder of the road. The final collision was due to the driver of the following school bus not maintaining the recommended minimum distance from the lead school bus in the seconds preceding the accident. Contributing to the severity of the accident was the lack of forward collision warning systems on the two school buses. As a result of this investigation, the NTSB urges the Federal Motor Carrier Safety Administration (FMCSA) to take action on four previously issued safety recommendations that were intended to prevent accidents and save lives. The two reiterated and reclassified safety recommendations address the placement of video event recorders (VER) in all heavy commercial vehicles and motor carrier review of that information. In addition, the NTSB reiterates two safety recommendations on the medical oversight of interstate commercial drivers? Video Event Recorders A VER is a device designed to capture video and other parameters related to operator and vehicle performance. Current VERs are capable of recording forward-looking video, interior video, interior audio, lateral acceleration, longitudinal acceleration, and global positioning system data, among other parameters. VERs may also be configured to record manually when activated by the driver or automatically when preconfigured thresholds are met on such events as hard braking or steering. When the VER is triggered, it typically stores a video recording of the seconds prior to, during, and after the event. VER systems are available for use in private, public, and commercial vehicles. The NTSB has recommended that the FMCSA require VERs in commercial vehicles over 10,000 pounds and that carriers use VERs to manage their drivers' performance. The NTSB recently issued the following two recommendations to the FMCSA as a result of its investigation of a truck-tractor semitrailer rear-end collision into passenger vehicles on 1-44 near Miami, Oklahoma: 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 systemwide performance-monitoring programs. (H-10-10) Require motor carriers to review and use video event recorder information in conjunction with other performance data to verify that driver actions are in accordance with company and regulatory rules and procedures essential to safety. (H-10-11) Each recommendation is currently classified "Open-Initial Response Received." In correspondence dated September 1, 2011, the FMCSA acknowledged the NTSB interest in improving motor carrier safety through the installation of VERs in all commercial motor vehicles. However, the FMCSA asserts that it is important to recognize that such recorders capture only a brief period of time prior to a safety-critical event (such as a crash, near crash, or unintended lane departure) and would be reviewed only by enforcement personnel or the motor carrier during an enforcement intervention. Additionally, VERs would not record unsafe driving behaviors that occur without a safety-critical event as a trigger. For these reasons, the FMCSA maintains that its Compliance, Safety, Accountability (CSA) program, launched in December 2010, offers better monitoring of a carrier's safety performance. Although the NTSB acknowledges that the CSA program will offer improved monitoring of drivers and carriers, there is enough evidence from this and past accident investigations that VERs can provide a level of oversight beyond that available through CSA. In addition, VERs can help drivers and carriers identify unsafe driver behaviors and situations before they result in an accident. The NTSB analysis of events leading to the Gray Summit collisions was greatly assisted by the presence of a video unit on the following school bus. Using the video, NTSB investigators were able to determine the speed of the GMC pickup approximately I minute prior to the collision, the speed of the following bus (and also to infer the speed of the lead school bus), and when the driver of the following bus began to take evasive action. However, had each commercial vehicle been equipped with a VER, as recommended by the NTSB, the accident sequence would have been more clearly understood; that is: • A VER on the Volvo tractor would have clarified whether it was moving or stopped when it was hit by the GMC pickup. • A VER on the motorcoach that pulled over to the shoulder would have more dearly shown when the GMC pickup driver entered the right lane, the actions of the motorcoach driver after the initial collision, and the timing of the subsequent collisions involving the two school buses. • A VER on the lead school bus would have allowed investigators to determine how the driver's visual scanning behavior factored into the second collision. • A VER on the following school bus would have allowed investigators to more accurately determine the distance between the two buses. VER recordings could be reviewed by carriers, school officials, law enforcement, and regulators in developing programs to encourage safe driving behavior and in improving vehicle and roadway designs. As useful as VER data are for analyzing accidents, their biggest benefit may be the potential to prevent accidents. When used in combination with a driver management program, VERs have been shown to reduce the occurrence of accidents involving emergency vehicles, novice drivers, and commercial drivers. In an FMCSA study, commercial vehicles were equipped with VERs, and baseline performance was measured over 4 weeks for the drivers of those vehicles. Over the next 13 weeks, the drivers were coached on their driving, based on the driving errors captured by the VERs. As a result of targeted coaching, the overall occurrence of unsafe events decreased significantly among the commercial drivers. Of the two carriers involved in this study, one experienced a 38 percent reduction in the mean rate of recorded safety-related events per 10,000 vehicle miles traveled, while the other experienced a 52 percent reduction in recorded safety-related events. The presence of VERs on all school buses, in combination with a driver management program, could assist carriers and school districts alike in identifying and addressing systemic factors in school bus operations that increase the risk of accidents. VER data could also be used to target risky or improper driver behavior before it leads to an accident. The NTSB concluded that had the Volvo tractor, the two school buses, and the motorcoach been required to have VERs, the events leading up to this accident could have been more definitively assessed. Additionally, the NTSB concluded that the use of VER data for managing driver behavior could assist school bus operators in identifying driver performance issues before they lead to accidents. Therefore, the NTSB reiterates Safety Recommendations H-10-10 and -11 to the FMCSA. Further, though the NTSB recognizes the possible monitoring benefits of the CSA program, the NTSB reclassifies these two recommendations OPEN--UNACCEPTABLE RESPONSE because the FMCSA has not yet required the installation of VERs or the use of the captured VER information. Medical Oversight During the course of its investigation, the NTSB found that the driver of the Volvo tractor had a medical condition that should have precluded licensure. However, witnesses confirmed that the driver had slowed his vehicle due to the traffic congestion ahead, and there w.ere no reports indicating that he had been driving erratically prior to the accident, which strongly suggest that he was not medically incapacitated at the time. The NTSB concluded that the medical condition of the Volvo tractor driver did not cause or contribute to the accident. However, the NTSB is concerned that in the 10 years since its report on the 1999 New Orleans motorcoach accident, commercial drivers with disqualifying medical conditions are still able to obtain current medical certificates and commercial driver licenses (CDL). Medical records indicate that in 2003, before the driver of the Volvo tractor obtained a CDL, he was warned by his primary care physician not to drive or operate machinery. By not divulging his medical history to a commercial driver fitness examiner, he subsequently obtained a COL and current medical certificate. The driver was licensed in West Virginia, which does not provide anonymity or legal protection to health care providers or anyone else who reports an individual as unfit to operate a vehicle. This circumstance makes it unlikely that a physician, employer, or concerned citizen with knowledge of a driver's illness would come forward to report an unfit driver to licensing authorities. As a result of its investigation into the New Orleans accident and testimony gathered at the subsequent hearing on COL and driver medical oversight, the NTSB recommended in 2001 that the FMCSA develop a comprehensive medical oversight program for interstate commercial drivers. Two of the eight program elements recommended were covered by the following safety recommendations: Develop a comprehensive medical oversight program for interstate commercial drivers that contains the following program elements: the review process prevents, or identifies and corrects, the inappropriate issuance of medical certification. (H-01-21) Develop a comprehensive medical oversight program for interstate commercial drivers that contains the following program elements: mechanisms for reporting medical conditions to the medical certification and reviewing authority and for evaluating these conditions between medical certification exams are in place; individuals, health care providers, and employers are aware of these mechanisms. (H-01-24) Safety Recommendations H-01-21 and -24 are each classified "Open-Unacceptable Response." The FMCSA has made progress on most of the eight program elements; for example, the agency published a Notice of Proposed Rulemaking in December 2008 to create a national registry of certified medical examiners, an initiative that could significantly reduce doctor shopping if a final rule is implemented. Yet, it is still possible for a driver to withhold information about a disqualifying condition from a fitness examiner and secure a valid medical certificate. To rectify this situation, all health care providers need to be made aware that the motoring public is at risk if a commercial driver is allowed to operate with a disqualifying condition. Mechanisms are also needed to encourage the reporting of medical conditions to the medical certification and reviewing authority and to evaluate these conditions between medical certification exams. The NTSB continues to be concerned that 41 states still do not require unfit drivers to be reported in good faith to a regulatory authority. Additionally, 19 states do not offer immunity to health care providers who, in good faith, report an unfit driver. For these reasons, the NTSB reiterates Safety Recommendations H-O 1-21 and -24 to the FMCSA. As a result of this accident investigation, the NTSB issued new safety recommendations to the National Highway Traffic Safety Administration, the 50 states and the District of Columbia, the state of Missouri, the Missouri Department of Elementary and Secondary Education, CTIA-The Wireless Association and the Consumer Electronics Association, and the National Association of State Directors of Pupil Transportation Services, the National Association for Pupil Transportation, and the National School Transportation Association. The NTSB also reiterated previously issued recommendations to the National Highway Traffic Safety Administration and the American Association of Motor Vehicle Administrators. Please refer to reiterated and reclassified Safety Recommendations H-10-10 and -11 and reiterated Safety Recommendations H-01-21 and -24 in your reply.

Date: 9/1/2011
Response: CC# 201100337: - From Anne S. Ferro, Administrator: Based on the reasons cited above in safety recommendation H-10-10, FMCSA respectfully requests that NTSB classify safety recommendation H-10-11 as "Closed-Acceptable Alternate Response." We share the NTSB's goal of improving motor carrier safety in order to make our roads and highways safer for everyone and believe the actions described above are responsive to safety recommendations H-10-08 through H-10-11.