Presented as part of ABA’s BISC & BusMARC 2021 Virtual Safety & Maintenance Series
As part of the ongoing Virtual Safety & Maintenance series, the American Bus Association (ABA) hosted an educational webinar addressing why and how companies can implement a fatigue risk management program (FMP), reduce fatigue-related accidents, and what we can learn from past accidents and severe crashes.
The webinar was presented by Mike Fox, senior highway crash investigator with the National Transportation Safety Board (NTSB).
The NTSB is an independent federal agency charged by Congress with investigating every civil aviation accident in the United States, and significant accidents in other modes of transportation including marine, rail, pipeline, and highway. In addition, the NTSB carries out special studies concerning transportation safety issues, provides assistance to victims and their family members impacted by major transportation disasters, and makes recommendations to the industry as well as the government on what steps can be taken to avoid similar accidents in the future.
Every two years, the NTSB publishes the “Most Wanted List,” a premiere advocacy tool that identifies the top safety improvements that can be made across all modes to prevent accidents, minimize injuries, and save lives in the future.
“It takes approximately 12 to 18 months to complete an investigation,” Fox said. “In addition to the on-scene investigation, our investigators conduct follow up investigations and interviews. We also perform testing or research and then we have an involved report-writing process.”
The NTSB produces two types of reports. A brief, which is a modified report, or a full report that results in a public board meeting in Washington. The NTSB has issued over 200 fatigue related recommendations across all modes.
Investigating Fatigue
During the initial days of a crash investigation, the NTSB analyzes all the physical evidence at the crash site utilizing a 3D scanner to map the scene to determine the driver’s input and actions during the crash sequence. Fox said median crossover, run of the road, over correction steering, and little or no braking at the end of a traffic queue are possible signs of fatigue crashes.
A thorough examination of the driver and carrier’s Hours of Service (HOS) compliance are performed – including a reconstruction of the driver’s most recent 72-hour history prior to the crash and reviewing all rest periods which were available to the driver leading up to the crash. Finally, all available electronic records for the driver are examined, which would include the driver’s Electronic Logging Device (ELD), any on-board recording devices, as well as the driver’s cell phone records.
The second phase of investigating fatigue is conducted during a ‘human factors’ investigation.
“We usually start with the driver’s DOT physical and see if the driver has had a restricted medical certificate,” Fox said. “We will also obtain the driver’s medical records and see if the driver was on any medications at the time of the crash. We will also get the driver’s toxicology.”
Highlight Crash Investigations
On October 6th, 2018, in Schoharie, NY, a 2001 Ford Excursion stretch limousine operated by Prestige Limousine was traveling southbound on Route 30, approaching the intersection of state route 30A. The limo was occupied by a 53-year-old driver and 17 passengers. The limo was traveling down a steep grade as indicated by the red arrow. The driver was unable to slow or stop the vehicle. He went through the intersection and into the parking lot of a local restaurant. The limo struck a parked car and two pedestrians standing in lot before landing in a ravine and colliding with an earthen embankment. As a result of this crash, the driver and all the passengers of the limo were fatally injured. Two pedestrians that were struck in the parking lot were also killed, resulting in 20 total fatalities.
“We held a board meeting for the Schoharie, New York, limousine crash,” Fox said. “And we determined the probable cause of the Schoharie crash was Prestige Limousine’s egregious disregard for safety in dispatching a stretch limousine with an Out-of-Service order resulting in the failure of its brake system while descending a steep grade of New York State Route 30.”
According to Fox, additional contributing factors included New York State DOT’s ineffective oversight of Prestige Limousine, despite its knowledge of the carrier’s multiple repair verification process. Further contributing to the crash was the New York DMV’s inadequate oversight of state license inspection stations and its failure to properly register the limousine – which enabled Prestige to circumvent the state’s safety regulations.
“There were numerous safety recommendations that came out of this report,” Fox said. “Of note, two were that the Federal Motor Carrier Safety Administration (FMCSA) provide guidance and best practices to states to enforce carrier compliance with state-issued Out-of-Service orders, and prevent vehicles and drivers from continuing to operate without authority after being cited for out of service violations.”
“We also issued two recommendations to New York State,” he continued, “requiring the New York DOT to implement their recommendations cited in the New York State’s Comptroller report to address vehicle repair certification requirements and improve carrier compliance with Out-of-Service violations and enforce actions for Out-Of-Service vehicles.”
The last recommendation was issued to the National Limousine Association, requesting that they inform their members of the importance of verifying the safety of all vehicles planned for passenger transportation.
Why Have a Fatigue Management Program?
The NTSB has recommended that the industry develop a fatigue management program such as the one modeled after the North American Fatigue Management Program, a four-year collaborative project between U.S. and Canadian governments, motor carriers, the insurance industry, and researchers. The purpose of the project was to raise awareness of driving drowsy and develop a fatigue management education that would be useful for drivers, managers, dispatchers, and family members.
According to Fox, there are four key elements of implementing an FMP. The first is safety culture.
“Safety culture can be a difficult term to define,” Fox said. “The North American Fatigue Management Program defines safety culture as the ‘safety triad,’ which consists of three factors that influence safety. The first factor is the person. Each person has feelings, beliefs, and attitudes that influence how they perform their job. The second factor is the environment. The equipment, tools, and management affect how the driver reacts to different situations. The third factor is behavior. This factor is the action taken by the driver in a given situation.”
The second element of a fatigue management program is establishing policies and procedures. Having established policies and procedures helps the company structure and maintain safety culture in the organization. Policies need to be written, reviewed, and updated.
“A great tool to have is a driver handbook,” Fox said. “This might be a good place to put your company policies, as well as other issue areas such as adverse driving, sleep apnea and driver wellness checks.”
The third element of a fatigue management program is training and education. Industry best practices typically have initial training when first hired. More advanced training programs include recurrent or annual training, as well as remedial training. According to Fox, training should cover Hours-of-Service regulations, as well as how a driver spends their off-duty time obtaining adequate rest.
The final element for fatigue risk management program is evaluation.
“It is very important to have mechanisms to evaluate the success of your program,” Fox said. “One method is to review the accident register or loss run reports. The company should always be making it a corporate goal to attempt to reach zero crashes.”
“Not managing the risk of fatigue can be deadly,” he explained. “It is important to understand that people are not machines and they cannot work 24 hours per day. Fatigue can lead to poor decision making, slowed response, risky behavior, and loss of situational awareness. Commercial drivers are most vulnerable because they often operate independently.”