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Safety Recommendation Details

Safety Recommendation H-13-037
Details
Synopsis: On Thursday, February 16, 2012, about 8:15 a.m. eastern standard time, near Chesterfield, New Jersey, a Garden State Transport Corporation 2012 IC Bus, LLC, school bus was transporting 25 kindergarten–sixth-grade students to Chesterfield Elementary School. The bus was traveling north on Burlington County Road (BCR) 660 through the intersection with BCR 528, while a Herman’s Trucking Inc. 2004 Mack roll-off1 truck with a fully loaded dump container was traveling east on BCR 528, approaching the intersection. The school bus driver had stopped at the flashing red traffic beacon and STOP sign. As the bus pulled away from just forward of the white stop line on BCR 660 and entered the intersection, it failed to yield to the truck and was struck behind the left rear axle. The bus rotated nearly 180 degrees and subsequently struck a traffic beacon support pole. One bus passenger was killed. Five bus passengers sustained serious injuries, 10 bus passengers and the bus driver received minor injuries, and nine bus passengers and the truck driver were uninjured. The National Transportation Safety Board (NTSB) determines that the probable cause of the Chesterfield, New Jersey, crash was the school bus driver’s failure to observe the Mack roll-off truck, which was approaching the intersection within a hazardous proximity. Contributing to the school bus driver’s reduced vigilance were cognitive decrements due to fatigue as a result of acute sleep loss, chronic sleep debt, and poor sleep quality, in combination with, and exacerbated by, sedative side effects from his use of prescription medications. Contributing to the severity of the crash was the truck driver’s operation of his vehicle in excess of the posted speed limit, in addition to his failure to ensure that the weight of the vehicle was within allowable operating restrictions. Further contributing to the severity of the crash were the defective brakes on the truck and its overweight condition due to poor vehicle oversight by Herman’s Trucking, along with improper installation of the lift axle brake system by the final stage manufacturer—all of which degraded the truck’s braking performance. Contributing to the severity of passenger injuries were the nonuse or misuse of school bus passenger lap belts; the lack of passenger protection from interior sidewalls, sidewall components, and seat frames; and the high lateral and rotational forces in the back portion of the bus.
Recommendation: TO THE SCHOOL BUS MANUFACTURERS TECHNICAL COUNCIL: Develop a recommended practice for establishing and safeguarding the structural integrity of the entire school bus seating and restraint system, including the seat pan attachment to the seat frame, in severe crashes—in particular, those involving lateral impacts with vehicles of large mass.
Original recommendation transmittal letter: PDF
Overall Status: Open Acceptable Alternate Response
Mode: Highway
Location: Chesterfield, NJ, United States
Is Reiterated: No
Is Hazmat: No
Is NPRM: No
Accident #: HWY12MH007
Accident Reports: School Bus and Truck Collision at Intersection
Report #: HAR-13-01
Accident Date: 2/16/2012
Issue Date: 9/9/2013
Date Closed:
Addressee(s) and Addressee Status: School Bus Manufacturers Technical Council (Open Acceptable Alternate Response)
Keyword(s):

Safety Recommendation History
From: NTSB
To: School Bus Manufacturers Technical Council
Date: 10/26/2015
Response: We appreciate your SBMTC members’ efforts to find the best way of implementing this recommendation. However, we are disappointed by your decision to petition the National Highway Traffic Safety Administration (NHTSA) to study the integrity of school bus seating system designs, including the newly required self-latching seat designs. We understand that you believe that a solution offered by NHTSA will ensure design consistency among all manufacturers, but we believe that you have sufficient influence among the majority of school bus manufacturers to address this important safety concern more efficiently. Nevertheless, your action will constitute an acceptable alternate means of accomplishing this recommendation. Accordingly, pending your notifying us of NHTSA’s decision regarding your petition and the subsequent issuance of guidance or a standard to address the recommended action, Safety Recommendation H-13-37 is classified OPEN—ACCEPTABLE ALTERNATE RESPONSE.

From: School Bus Manufacturers Technical Council
To: NTSB
Date: 7/31/2015
Response: -From Ken Whisnant, Chairman, School Bus Manufacturers Technical Council: The SBMTC believes that any recommended practice we develop on our own would not have lasting or binding results in the final product for years to come. This is because the SBMTC has neither the authority nor a mandate to enforce regulations within the school bus industry. Therefore, we believe the best way to develop such a recommended practice or regulation is to petition the National Highway Traffic Safety Administration (NHTSA) to study the data contained in the NTSB crash report and to conduct any additional studies and develop new regulation(s) and/or changes in current regulation(s), if the agency’s review indicates that such actions are warranted. This approach ensures that all systems required on school buses work in conjunction with any new regulation and that there are no unintended consequences of such changes. Implementing the NTSB recommendation by means of a federal safety standard, if warranted, would require that all school bus and school bus seat manufacturers currently in the market and any potential new manufacturers adhere to the same level of compliance testing and quality assurance that goes into making school buses the safest form of transportation in the world today. We believe that manufacturers are already incorporating lateral seat stability into their seat designs, pursuant to changes in Federal Motor Vehicle Safety Standard (FMVSS) 222 that became effective for all new school buses on October 21, 2009. Nevertheless, our petition to NHTSA (attached) requests that the agency review lateral stability as it pertains to seat cushion retention requirements. We will also inform the members of NASDPTS of this request, which will include the NASDPTS Supplier Council, within which all current school bus original equipment manufacturers and passenger seat manufacturers are represented. We value the opportunity to respond to the NTSB’s important safety recommendation and remain available to assist the Safety Board.

From: NTSB
To: School Bus Manufacturers Technical Council
Date: 8/13/2014
Response: We appreciate your members’ efforts to understand this recommendation. Although your proposed inspection protocol would help to ensure that bus seats are latched, we are concerned that it neither tests, nor fixes problems with, seating system integrity, especially regarding control of lateral impact forces. This recommendation is intended to address the integrity of school bus seating system designs, including the newly required self-latching seat designs, through the development of testing and guidance. We urge the SBMTC to reconsider its position and complete the recommended action; until such action has been taken, Safety Recommendation H-13-37 is classified OPEN—UNACCEPTABLE RESPONSE.

From: School Bus Manufacturers Technical Council
To: NTSB
Date: 6/19/2014
Response: -From Ken Whisnant, Chairman, School Bus Manufacturers Technical Council: The accidents were similar in that they both involved school buses of the same size and mass, they were both struck in the side near the rear axle by vehicles of large mass after the school bus entered an intersection into the path of an oncoming truck. In both cases, the bus remained upright and rotated approximately 180-degrees after being struck. In the Chesterfield, NJ accident, the school bus, a 2012 model, was struck by a dump truck weighing 84,950 lbs and traveling between 40-45 mph. In Port St. Lucie, the 2004 model school bus was struck by a truck and trailer weighing 78,600 lbs and traveling 50-55 mph. Unfortunately, both accidents resulted in a fatality to a child on the school bus. Regarding the performance of the seat pan (bottom cushion) attachment to the seat frame, there were two distinct differences. In the Port St. Lucie, Florida accident a single seat cushion dislodged during the impact sequence. This seat, driver’s side- row 10, was where the fatally injured child was sitting. In the Chesterfield, New Jersey accident all the seat pans remained attached. There was a key difference between the seat frames in that the Chesterfield bus had self-latching cushions whereas the Port St. Lucie bus had turn style latches that required manually turning the latch after lowering the cushion onto the frame. Historically, school buses have been required to provide seats that have flip-up seat cushions to allow customers to clean under the seats more easily. Most cushion designs utilized some type of turn clip that retained the cushion once this clip was turned and oriented in the latched position. From SURVIVAL FACTORS GROUP CHAIRMAN’S FACTUAL REPORT for the Port Saint Lucie, FL accident page 11 states ‘Some of the latches were found to be loose…’ and on page 12 ‘The seat cushion attachments were inspected, and it was noted that many of the seat cushions were not latched down. The seat cushions without the latch engaged were: Driver side rows 2, 3, 4, 6, 8, 9, 10 and 11 and Passenger side rows 1, 2 ,4, 6, 8, 10, and 11 Deformation of the front seat cushion brackets were also found during the investigation. This deformation of the front brackets was not limited to occupied seats as both rows 4 and 6 on the driver’s side was found with the front brackets deformed and these seats were unoccupied per Figure 2- Seating Chart. However, these seats were also included in the list of seats found with cushions in the unlatched position. Therefore it is reasonable to attribute the cushion’s front bracket deformation to whether the cushion latch was engaged at the time of the accident. All elements of the hardware are necessary in order to maintain the integrity of the seat cushion attachment to the seat frame in the event of an accident. Unlatched cushions will put greater stress on the remaining hardware as a result as can be seen in Figure 1. With the 2008 release of NPRM for FMVSS 222, flip up cushions were required to self-latch when the cushion was closed because manually operated cushions could be left unlatched after cleaning and this change could benefit safety in a crash situation. The NPRM contained the following language: Reference: 2008 NPRM, Federal Motor Vehicle Safety Standards; Seating Systems, Occupant Crash Protection, Seat Belt Assembly Anchorages, School Bus Passenger Seating and Crash Protection [Docket No. NHTSA-2008-0163] “Manually operated seat cushion latches can inadvertently be left unlatched after cleaning, and that the proposed self-latching mechanisms could ‘benefit safety in a crash situation.’ S5.1.5 Seat Cushion Retention (a) Seat cushion latching. For school buses manufactured on or after October 21, 2009, school bus passenger seat cushions equipped with attachment devices that allow for the seat cushion to be removable without tools or to flip up must have a self-latching mechanism that is activated when a 22-kg (48.4-pound) mass is placed on the center of the seat cushion with the seat cushion in the down position. As a result of this NPRM, all school bus seats produced since October 21, 2009 have some method to control lateral movement of the cushion. For cushions that flip up, these stops serve to ensure engagement of the match mechanism to prevent the cushion from potentially sliding and disengaging. Old style turn latch cushions had no features to limit the lateral movement. The Port St. Lucie school bus was manufactured in 2004 and did not have such features. Not all seats manufactured after October 2009 use flip up cushion designs as can be seen in Figure 5 and 6 below. It is impossible to say with certainty if the cushion that became dislodged was due to the fact the turn latch was not in the latched position at the time of the accident. However, seat cushion retention as this cushion was designed to handle certainly depends on it being latched. For that reason, ensuring that the seat cushions with manual turn latches are correctly latched is a means of safeguarding the structural integrity of the entire seat system including occupant interaction with the restraint system. From Highway Accident Report NTSB/HAR-13/01 PB2013-106638 page 32 for the Chesterfield accident it states: “All seat pans were attached postcrash” and there was no mention in any of the reports of damage to the seat securement hardware. The fact that these seat cushions all remained latched is significant as this accident actually resulted in two impacts for the school bus from opposing sides. First, the truck struck the left side of the school bus 65 inches rearward of the axle causing the bus to rotate almost 180 degrees and strike a traffic beacon support pole also behind the rear axle just one passenger seat row forward from the initial impact. This secondary impact was high enough to cause lateral intrusion into the aisle by almost 9 inches. School bus manufacturers and seat manufacturers response to NHTSA’s update to FMVSS 222 Seat cushion retention S5.1.5, to add a self-latching mechanism on seat cushions built after October 21, 2009, did establish safeguarding the school bus seating and restraint systems as was evident in the Chesterfield crash. Ensuring that the seat pan attachment to the seat frame is fully in the latched position on seat cushions built prior to October 21, 2009, would provide a safeguard to the structural integrity of the entire school bus seating and restraint system for those seats as well. Therefore the SBMTC, will request an update to the National School Transportation Specifications and Procedures, school bus driver’s pre-trip inspection and annual inspections, to include a verification that buses manufactured before October 2009, having flip-up seat cushions with manual retention, shall be inspected and verified that the manual retention is in the latched position.

From: NTSB
To: School Bus Manufacturers Technical Council
Date: 12/19/2013
Response: The SBMTC indicated concerns regarding the availability of detailed technical information in our report on the Chesterfield, New Jersey, and Port St. Lucie, Florida, accidents. In lieu of an official written response, we would like to meet with representatives of the SBMTC to discuss your concerns and this recommendation in person. We will delay our formal review of the SBMTC’s response and classification of the recommendation until we have an opportunity to meet.

From: School Bus Manufacturers Technical Council
To: NTSB
Date: 12/6/2013
Response: Ken Whisnant, Chairman: From what the SBMTC can ascertain from the limited information in this report and review of the bus design, a seat pan (bottom cushion) dislodged in the Port St. Lucie, Florida incident. There were no details as to how this contributed to passenger injuries. In the details of the report regarding the incidents, near Chesterfield, New Jersey, February 16, 2012 or Port St. Lucie, Florida, March 26, 2012, there is no evidence that the structural integrity of any part of the school bus seating and restraint system, including the seat pan attachment to the seat frame, caused passenger injuries. Furthermore, the NTSB, NHTSA or school bus seating manufacturers have not conducted any studies on the injuries associated with the entire school bus seating and restraint system, including the seat pan attachment to the seat frame, with regards to lateral impacts between large trucks and buses. The Port St. Lucie, Florida incident bus was manufactured on May 24, 2004 which is before the October 2009, NHTSA FMVSS 222 change which added requirements to the seat cushion retention to require the seat cushion to be self-latching. The NPRM contained the following: Reference: 2008 NPRM, Federal Motor Vehicle Safety Standards; Seating Systems, Occupant Crash Protection, Seat Belt Assembly Anchorages, School Bus Passenger Seating and Crash Protection [Docket No. NHTSA–2008–0163] “manually operated seat cushion latches can inadvertently be left unlatched after cleaning, and that the proposed self-latching mechanisms could ‘‘benefit safety in a crash situation.’’.” S5.1.5 Seat cushion retention. (a) Seat cushion latching. For school buses manufactured on or after October 21, 2009, school bus passenger seat cushions equipped with attachment devices that allow for the seat cushion to be removable without tools or to flip up must have a self-latching mechanism that is activated when a 22-kg (48.4-pound) mass is placed on the center of the seat cushion with the seat cushion in the down position. The SBMTC cannot speculate as to the requirements for safeguarding the structural integrity of the entire school bus seating and restraint system, including the seat pan attachment to the seat frame, in severe crashes—in particular, those involving lateral impacts with vehicles of large mass. The details of the compound crash dynamics as they relate to the seating restraint system in accidents such as those in the report (Accident Report NTSB/HAR-13/01 PB2013-106638) do not provide speculation or requirements in the areas of establishing and safeguarding the entire school bus seating and restraint systems. NHTSA’s update to FMVSS 222, Seat cushion retention S5.1.5, to add a self-latching mechanism, did establish safeguarding the school bus seating and restraint systems. Prior to this, the school bus seat pan attachment to the seat frame may have been retained by way of a manual latching method. It may be possible that the seat cushions in these accidents were not fully in the latched position. Ensuring that the seat pan attachment to the seat frame is fully in the latched position will provide a safeguard to the structural integrity of the entire school bus seating and restraint system. The SBMTC therefore, will request an update to the National School Transportation Specifications & Procedures, school bus driver’s pre-trip inspection and annual inspections, to include a verification that buses manufactured before October 2009, having flip-up seat cushions with manual retention, shall be inspected and verified that the manual retention is in the latched position. The SBMTC trusts that the above will address the H-13-37 recommendation.