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Safety Recommendation Details

Safety Recommendation H-12-030
Synopsis: On Tuesday, May 31, 2011, approximately 4:55 a.m. eastern daylight time, a 2000 Setra 59-passenger motorcoach operated by Sky Express, Inc., occupied by a driver and 58 passengers, was traveling north on Interstate 95 in the right lane of the three northbound lanes near Doswell, Virginia. The motorcoach drifted from the highway to the right, struck a cable barrier, rotated counterclockwise around its vertical axis, overturned to the right, and rolled onto its roof. As a result of the accident, 4 of the 58 passengers were killed, 14 received serious injuries, and 35 received minor injuries. The driver sustained minor injuries and refused medical treatment. The National Transportation Safety Board (NTSB) determines that the probable cause of this accident was the failure of the motorcoach driver to maintain control of the vehicle due to his falling asleep while driving because of fatigue resulting from acute sleep loss, poor sleep quality, and circadian disruption and the failure of Sky Express, Inc., management to follow adequate safety practices and to exercise safety oversight of the driver. Contributing to the accident was the Federal Motor Carrier Safety Administration's lack of adequate oversight of Sky Express, Inc., which allowed the company to continue operations despite known safety issues. Contributing to the fatalities and the severity of the injuries was the lack of a comprehensive occupant protection system, including systems for providing passenger restraint and for ensuring sufficient roof strength.
Recommendation: TO THE FEDERAL MOTOR CARRIER SAFETY ADMINISTRATION: Incorporate scientifically based fatigue mitigation strategies into the hours-of-service regulations for passenger-carrying drivers who operate during the nighttime window of circadian low.
Original recommendation transmittal letter: PDF
Overall Status: Open - Unacceptable Response
Mode: Highway
Location: Doswell, VA, United States
Is Reiterated: Yes
Is Hazmat: No
Accident #: HWY11MH010
Accident Reports: Motorcoach Roadway Departure and Overturn on Interstate 95
Report #: HAR-12-02
Accident Date: 5/31/2011
Issue Date: 8/16/2012
Date Closed:
Addressee(s) and Addressee Status: FMCSA (Open - Unacceptable Response)

Safety Recommendation History
From: NTSB
Date: 6/3/2019
Response: We are disappointed that you cancelled rulemaking related to this recommendation and have no plans to reinitiate rulemaking efforts. Unfortunately, we continue to see crashes where HOS requirements for drivers of passenger-carrying vehicles play a role, which has led us to include “Reduce Fatigue-Related Accidents” as an advocacy issue area on our 2019–2020 Most Wanted List. Because we continue to believe that the HOS regulations for motorcoach and bus drivers would be more effective if they addressed the scientifically established risk of drivers operating during the nighttime window of circadian low, we urge you to reconsider your position on this issue. Pending such action, Safety Recommendation H-12-30 remains classified OPEN--UNACCEPTABLE RESPONSE.

Date: 1/18/2019
Response: -From Michael Jordan, Strategic Planning and Program Evaluation Division, Federal Motor Carrier Safety Administration: On August 8, 2018, and December 4, 2018, representatives from the Federal Motor Carrier Safety Administration (FMCSA) and National Transportation Safety Board (NTSB) met to discuss the status of 13 safety recommendations. This memorandum communicates the status updates discussed at those meetings. Source: Highway Accident Report (NTSB/HAR-12/02); Doswell, Virginia (2011-05-31) Current Classification: Open - Unacceptable Response Requested Classification: Closed Status Update: • On June 20, 2017, FMCSA submitted a status update to NTSB for safety recommendation H-12-030 that stated FMCSA’s work on the recommended item of rulemaking had been suspended. • NTSB subsequently responded on December 6, 2017, and expressed concern that hours of service regulations for motorcoach and bus drivers would be more effective if they addressed the scientifically established risk of drivers operating during the night-time window of circadian low. • FMCSA acknowledges NTSB’s concern with regard to improving hours of service regulations. However, the Agency has cancelled the recommended item of rulemaking and it no longer appears on the Agency’s regulatory agenda. FMCSA has no plans to reinitiate rulemaking on this issue. • FMCSA requests NTSB close safety recommendation H-12-030.

From: NTSB
Date: 12/6/2017
Response: We note that you have been examining the need to change HOS requirements for drivers of passenger-carrying vehicles by funding research reports, receiving recommendations from your Motor Carrier Safety Advisory Committee, and hearing participant comments at two listening sessions; however, we are concerned that you have not yet taken action on passenger-carrying HOS regulations, and that you recently suspended your rulemaking efforts. Because we continue to believe that the HOS regulations for motorcoach and bus drivers would be more effective if they addressed the scientifically established risk of drivers operating during the nighttime window of circadian low, this recommendation was reiterated in the 2017 Livingston, California, motorcoach run-off-the-road accident report. Accordingly, Safety Recommendation H-12-30 remains classified OPEN--UNACCEPTABLE RESPONSE.

From: NTSB
Date: 11/13/2017
Response: From the NTSB Highway Accident Report “Motorcoach Run-Off-the-Road and Collision with Vertical Highway Signpost, State Route 99, Livingston, California, August 2, 2016” HAR-17-03 Notation 57079: As a result of the Doswell crash investigation, involving a fatigued motorcoach driver operating on an inverted schedule, the NTSB recommended that the FMCSA (NTSB 2012a): Incorporate scientifically based fatigue mitigation strategies into the HOS regulations for passenger-carrying drivers who operate during the nighttime window of circadian low. (H-12-30) Safety Recommendation H-12-30 is classified “Open—Acceptable Response.” The US Department of Transportation (DOT) has begun to address human circadian variability in its HOS regulations. For example, to help compensate for commercial passenger airline pilots being awake during the circadian low, the Federal Aviation Administration reduced the maximum flight duty period during nighttime hours. The FMCSA has been examining the need to change HOS requirements for drivers of passenger-carrying vehicles.68 Although the agency has funded research reports and received recommendations from its Motor Carrier Safety Advisory Committee, as well as participant support from two listening sessions, it has not taken action on passenger-carrying hours of service.69 The NTSB concludes that the CMV HOS regulations for motorcoach and bus drivers would be more effective if they addressed the scientifically established risk of drivers operating during the nighttime window of circadian low. The NTSB, therefore, reiterates Safety Recommendation H-12-30 to the FMCSA and reclassifies it OPEN—UNACCEPTABLE RESPONSE.

Date: 6/20/2017
Response: -From Michael J. Jordan, USDOT/FMCSA MC-PRS, Strategic Planning and Program Evaluation: • FMCSA’s work on the recommended rulemaking, a non-fixed 15-hour window of operation for motorcoach drivers, has been suspended and there is no plan to propose such modification. • In the meantime, FMCSA will continue to work with the motorcoach industry and provide outreach materials that concern fatigue management and mitigation, including the promotion of available materials located on the NAFMP Web site and encouragement for motor carriers to voluntarily implement and strengthen existing fatigue management programs. • In addition, FMCSA will continue to conduct outreach with those stakeholders that use motor coach operator services (e.g., schools, churches, retirement facilities, etc.) to educate them on the hours of service requirements and the importance of trip itineraries that allow drivers to obtain necessary rest. • FMCSA requests NTSB maintain the classification for safety recommendation H-12-030 as “Open – Acceptable Response.”

From: NTSB
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. Driver Fatigue To FMCSA: Incorporate scientifically based fatigue mitigation strategies into the hours-of-service regulations for passenger-carrying drivers who operate during the nighttime window of circadian low. (H-12-30) Require all motor carriers to adopt a fatigue management program based on the North American Fatigue Management Program guidelines for the management of fatigue in a motor carrier operating environment. (H 10 9) Implement a program to identify commercial drivers at high risk for obstructive sleep apnea and require that those drivers provide evidence through the medical certification process of having been appropriately evaluated and, if treatment is needed, effectively treated for that disorder before being granted unrestricted medical certification. (H-09-15) Develop and disseminate guidance for commercial drivers, employers, and physicians regarding the identification and treatment of individuals at high risk of obstructive sleep apnea (OSA), emphasizing that drivers who have OSA that is effectively treated are routinely approved for continued medical certification. (H-09-16) Develop and implement a plan to deploy technologies in commercial vehicles to reduce the occurrence of fatigue-related accidents. (H 08 13)

From: NTSB
Date: 3/28/2013
Response: We are encouraged by the FMCSA’s efforts to study the current passenger-carrying HOS regulations with information obtained from your Motor Carrier Safety Advisory Committee and public listening sessions. We look forward to receiving updates on the agency’s plans to include the recommended fatigue mitigation strategies in HOS regulations for passenger-carrying drivers. Until these actions are complete, Safety Recommendation H 12 30 is classified OPEN—ACCEPTABLE RESPONSE.

Date: 2/21/2013
Response: -From Anne S. Ferro, Administrator: I am pleased to provide the Federal Motor Carrier Safety Administration's (FMCSA) response to the National Transportation Safety Board's (NTSB) letter regarding Safety Recommendations H-12-29 through H-12-31. The Agency acknowledges the NTSB's thorough investigation into the May 31, 2011, motorcoach crash near Doswell, Virginia. The FMCSA shares your concern and commitment to transportation safety, especially pertaining to passenger carrier safety. Safety is FMCSA's number one priority and clearly shapes the Agency's agenda to ensure the safe operation of commercial motor vehicles (CMV) and to hold unsafe companies accountable for achieving safety compliance. The FMCSA does this through a mix of programs, rules, and enforcement tools framed on three guiding principles: to raise the safety bar to enter the industry; to require high safety standards to remain in the industry, and to remove high-risk carriers, drivers and service providers from operation. Everything the Agency does can be tied back to one or more of these principles. . Following the Doswell, Virginia, and other fatal motorcoach bus crashes along the Interstate 95 corridor, FMCSA launched an unprecedented investigation into bus companies operating in flagrant violation ofthe Agency's safety regulations. This investigation culminated into nine separate enforcement actions against three passenger carrier networks based on extensive information collected by FMCSA safety investigators and inspection data collected by State law enforcement partners during multiple bus safety strike forces and investigations. The Agency's investigations and data analysis found multiple patterns of serious safety violations by three networks of bus companies that deliberately structured their operations to evade Federal laws and regulations. The companies, which carried almost 2,000 passengers a day, showed flagrant disregard for the public's safety by using: • Drivers without valid commercial driver's licenses or medial qualification certificates; • Drivers who had not been properly drug tested; • Drivers who had exceeded the hours-of-service limits; and • Vehicles that were mechanically unsafe and in disrepair. The Agency continues to investigate companies operating under this type of management structure and will continue to take appropriate action against any of these companies as warranted. Another way FMC SA is working to achieve higher safety standards and remove unsafe drivers and carriers is through focused safety strike forces at the busiest travel destinations across the country and areas of non-traditional, curbside service. In Fiscal Year (FY) 2011 alone, the Agency and its State law enforcement partners conducted more than 114,000 inspections and 1,500 compliance reviews and issued 12 imminent hazard orders and 110 unsatisfactory/unfit determinations or failure to pay out-of-service (OOS) orders to passenger carriers. These were drastic actions taken against carriers that would not come into compliance with Agency regulations and had to be removed from service. 2 In 2012, FMC SA continued its strike force initiatives and conducted safety inspections of motorcoaches, tour buses, school buses, and other commercial passenger buses in 13 states and the District of Columbia, including (Connecticut, Delaware, Maine, Maryland, Massachusetts, New Hampshire, New Jersey, New York, Pennsylvania, Rhode Island, Vermont, Virginia, and West Virginia). In FY 2012, FMCSA conducted 124,153 inspections, 1,891 compliance reviews, issued 30 imminent hazard orders, and 108 unsatisfactory/unfit determinations or failure to pay OOS orders to passenger carriers. The FMCSA will continue to partner with State and local law enforcement to take part in the nationwide passenger carrier strike forces to strengthen commercial bus and driver safety. In September 2011, the u.S. Department of Transportation (DOT) hosted a National Motorcoach Safety Summit in Washington, DC, to increase awareness of the importance of motorcoach safety and to energize and empower stakeholders, partners, and the public to take action in making motorcoach transportation safer. To compliment this effort, FMC SA unveiled its "SaferBus Mobile App," a first-of-its-kind, multilingual smartphone and tablet application that gives bus riders a quick and free way to review a bus company's safety record before buying a ticket or booking group travel. The FMCSA also continues to encourage consumers to review its "Think Safety: Every Trip, Every Time" pre-trip safety checklist available online at the Agency's website. Consumers are also encouraged to report any unsafe bus company, vehicle, or driver to FMCSA through a toll-free hotline at 1-888-DOT-SAFT (1-888-368-7238) or through its online National Consumer Complaint Database. Likewise, FMCSA has actively been implementing the Department's Motorcoach Safety Action Plan (MSAP), first released in November 2009. The MSAP took a fresh look at motorcoach safety issues and identified actions to address outstanding safety problems with schedules for implementation. To date, more than 60 percent of the original FMCSA actions have been completed. On December 12, 2012, the Department released an updated MSAP. The updated plan highlights the Department's accomplishments from previous years and provides information on safety measures and new initiatives to improve the safety of motorcoach passengers. It reflects the integrated activities of the Department's safety agencies and incorporates the feedback of numerous motorcoach safety stakeholders during the 2011 Motorcoach Safety Summit. It expands on the initial 2009 version by focusing on driver fatigue, driver behavior, vehicle maintenance, operator oversight, crash avoidance measures, and occupant protection. It also includes new requirements and mandates under the "Moving Ahead for Progress in the 21st Century Act" (MAP-21) reauthorization legislation. The MAP-21 legislation requires various new motorcoach rulemakings and research projects, as well as requirements for improved oversight of motorcoach service providers. Specific to NTSB Safety Recommendations, H-12-29 through H-12-31, the Agency believes the initiatives outlined below address each of the respective recommendations. The current hours-of-service (HOS) rules for passenger carrier operations allow up to 10 hours of driving time following 8 consecutive hours off-duty. Driving is prohibited after the operator has accumulated 15 hours of on-duty time following 8 consecutive hours off-duty (15-hour rule). The 15-hour window may be extended by off-duty periods, unlike the 14-hour non-extendable window for drivers of property-carrying vehicles. With regard to weekly limitations, drivers of passenger-carrying vehicles are subject to a 60- or 70-hour rule but, unlike drivers of property carrying vehicles, they may not restart their calculations of weekly limits after 34 consecutive hours off-duty. In December 2011, at its Motor Carrier Safety Advisory Committee (MCSAC) meeting, the Agency tasked the committee to begin examining whether HOS requirements for drivers of passenger-carrying vehicles may need to be changed to enhance safety and to provide information, concepts, and ideas that FMC SA should consider relating to HOS requirements for drivers of passenger-carrying vehicles.4 The committee will provide a letter report to FMCSA in 2013. In addition, FMCSA held two public listening sessions, one in January 20125 at the American Bus Association's Marketplace 2012 in Grapevine, Texas, and the second in October 2012 at the California Bus Association Annual Convention in Santa Barbara, California, to solicit concepts, ideas, and information on its current HOS requirements for motorcoach drivers. Throughout the sessions, the Agency sought information relating to driving time, on-duty time, time-on-task function, and cumulative fatigue. The Agency will consider research reports, recommendations from its MCSAC, and the remarks of listening session participants in determining its next actions in motorcoach HOS. Based on the above, FMC SA respectfully requests that NTSB classify Safety Recommendation H -12-30 as "Open-Acceptable Response."