Just before 6:30 a.m. (eastern daylight savings time) on Tuesday,
November 1, 2016, a 2015 IC Bus 64-passenger school bus was traveling east in the 4000 block of Frederick Avenue in Baltimore, Maryland, when it was involved in two separate crashes. The school bus, operated by the motor carrier AAAfordable Transportation LLC, under contract to the Baltimore City Public Schools (BCPS), was occupied by the 67-year-old driver and a school bus attendant. No students were on the bus.
After the school bus traveled through the South Loudon Avenue intersection, it struck the rear of a 2012 Ford Mustang, which was also traveling east on Frederick Avenue. Upon impact, the car—occupied by a driver only—traveled 74 feet, struck the south curb of Frederick Avenue, collided with a brick wall and metal fence, and continued to a final position across the eastbound lane of Frederick Avenue.
Security camera videos from three locations recorded the school bus movement on Frederick Avenue. Based on video evidence, the bus was traveling about 57 mph when it crossed the camera fields of view moments before impact with the car. The bus slowed to 47 mph due to the collision. The posted speed limit on Frederick Avenue is 30 mph.
After striking the car, the school bus continued traveling east for about 820 feet, crossed the Frederick Avenue center turn lane, and entered the westbound travel lane. The school bus then struck the front and left side of an oncoming 2005 New Flyer transit bus operated by the Maryland Transit Administration (MTA). The transit bus was occupied by a 33-year-old driver and 13 passengers.
The transit bus was equipped with video surveillance cameras that continuously recorded the exterior and interior of the bus. The recorded videos were used to estimate the speed of each vehicle before impact. As the westbound transit bus approached the 3800 block of Frederick Avenue, its forward-facing video shows the eastbound school bus crossing into the center turn lane and then entering the path of the oncoming transit bus. The school bus was traveling 45 mph several seconds before impact, and the transit bus was traveling 39 mph at impact.
In November 2016, the NTSB began the investigation of two crashes involving school buses. Each crash was initiated when the driver lost control of the bus. In the November 1 crash in Baltimore, Maryland, the driver was epileptic and suffered a seizure. In the November 21 crash in Chattanooga, Tennessee, the driver was speeding while using a cell phone and ran off the road. In both cases, the school bus operators were private for-hire motor carriers. Although the specific safety issues differed, the crashes shared one common factor: poor driver oversight by both the school districts and the contracted motor carriers, which resulted in unsafe operation of the school buses. Between the two crashes, 12 people died and 37 were injured.
We determined that the probable cause of the Baltimore, Maryland, school bus crash was the loss of vehicle control due to incapacitation of the bus driver because of a seizure stemming from a long-standing seizure disorder; the bus driver’s continued operation of a school bus with a disqualifying medical condition and a fraudulently obtained commercial driver’s license; and the failure of AAAfordable Transportation and the Baltimore City Public Schools to provide adequate bus driver oversight, allowing the medically unfit driver to drive a commercial vehicle with a medical condition that they knew, or should have known, could lead to the unsafe operation of the school bus. Contributing to the severity of the crash was the lack of a collision avoidance system with automatic emergency braking on the school bus.
The crash investigations focused on the following safety issues: school districts’ lack of oversight of student transportation providers; poor management of unsafe school bus drivers by the motor carriers and school districts; medically unfit school bus drivers; commercial driver license fraud; occupant protection in large school buses; and the benefits of electronic stability control, automatic emergency braking, and event data recorders. The NTSB made safety recommendations to the Federal Motor Carrier Safety Administration; the National Highway Traffic Safety Administration (NHTSA); the states of Florida, Louisiana, New Jersey, and New York; 42 states, the District of Columbia, and the territory of Puerto Rico—which lack requirements for lap/shoulder belts on large school buses; the state of Maryland; the Maryland Department of Education; the Maryland Motor Vehicle Administration; five school bus transportation associations; National Express LLC; seven school bus manufacturers; five electronic health record companies; and Concentra, Inc. The report also reiterates four recommendations to NHTSA and reclassifies a recommendation to the Baltimore City Public Schools.
