Abstract: In May 2005, the National Transportation Safety Board (NTSB) began its investigation of a school bus accident that occurred in Liberty, Missouri. During the course of the investigation, information was uncovered that suggested pedal misapplication as a factor in the accident—that is, depressing the accelerator instead of, or in addition to, the brake pedal. The NTSB subsequently investigated four additional accidents—in Falls Township and Newtown, Pennsylvania; Asbury Park, New Jersey; and Nanuet, New York—involving heavy vehicles in which pedal misapplication was determined to be a factor. Despite varying circumstances, these five accidents share common elements. In all five, the drivers either reported a loss of braking or were observed by vehicle occupants to be unsuccessfully attempting to stop the vehicles, though no evidence of braking system failure was found.
Major safety issues identified by this special investigation of pedal misapplication in heavy vehicles include the need for brake transmission shift interlock systems; the need for increased analysis of pedal design configurations; the need for school bus drivers, in particular, to have annual refamiliarization training on all bus types that they might drive; the benefits of positive separation in transit areas to decrease the risks of unintended acceleration during loading and unloading activities; and the need for event data recorders in school buses and motorcoaches. As a result of this investigation, the NTSB makes recommendations to the National Highway Traffic Safety Administration, the National Association of State Directors of Pupil Transportation Services, and the National Association for Pupil Transportation. In addition, the NTSB reiterates and reclassifies two previously issued recommendations to the National Highway Traffic Safety Administration and reclassifies one previously issued recommendation to the Community Transportation Association of America.