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"Lessons Learned" is a series of drop-in articles prepared by the NTSB for use 
in publications of other organizations.  An index of articles is available at
http://www.ntsb.gov/events/journalist/lessons/lessons.htm
05/2005
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Lessons Learned from Accident Investigations
Bus Driver's Lack of Personal Responsibility Led to Crash 

     A deliberate and blatant lack of personal responsibility by the driver of a motorcoach, 
who fell asleep at the wheel, led to a crash that killed five people – an accident the 
National Transportation Safety Board said should never have happened. 

     The driver was charged by law authorities and convicted of manslaughter, assault, 
reckless driving and reckless endangerment. 

     "The tragic circumstances of this accident underscore how critical it is that every 
person in our transportation system be 100% committed to safety," said NTSB Chairman 
Ellen Engleman- Conners. "Do not operate a vehicle if you are tired and do not allow 
someone who is tired to get behind the wheel." 

     The NTSB issued a final report on an investigation into the crash of an Arrow Line 
motorcoach in Victor, NY in June 2002. "This crash has lessons for everyone in the 
motorcoach industry, from drivers to company management," Engleman-Conners said. 

     There were two motorcoaches en route from Niagara Falls, Ontario, Canada, to 
Waterbury, Connecticut. As one of the buses approached a highway exit near Victor, it 
departed the roadway, ran into a depressed grassy area between the eastbound exit and 
entrance ramp, and struck a W-beam guardrail. The motorcoach dragged 700 feet of the 
guardrail across the eastbound entrance ramp, vaulted over the entrance ramp roadway, 
landed on the south side shoulder of the entrance ramp, rolled 90 degrees onto its right 
side, and slid to rest. The guardrail dragged by the motorcoach struck three eastbound 
vehicles on the entrance ramp. Three occupants of these vehicles were uninjured, and six 
received minor injuries. Of the 48 people on the motorcoach, five passengers were killed, 
the driver and 41 passengers were injured, and one passenger was uninjured. 

     The NTSB said the driver of the motorcoach in the accident took no responsibility for 
being well rested and fit for duty, spending his off-duty time in a casino instead of 
sleeping. It also said several factors contributed to the accident, including a second Arrow 
Line motorcoach driver who, knowing that the accident driver was severely fatigued, did 
nothing to stop him from driving, and inadequate oversight of drivers by the company. 

     "The bottom line is that responsible drivers plan their off-duty hours so they get 
adequate sleep to avoid accidents and risking the lives of others," NTSB Chairman 
Engleman-Conners said. 

     During the investigation, the Safety Board learned that the accident driver arrived in 
Niagara Falls around 7:30 a.m. on Friday and spent his time in a local casino from 
approximately noon on Friday until 10 a.m. on Saturday when he returned to his room 
but did not sleep. He went back to the casino around 4 p.m. on Saturday where he 
remained until approximately 9 a.m. Sunday. Both Arrow Line motorcoaches departed 
about three and a half hours later. 

     The trip coordinator and several passengers told investigators that they were 
concerned about the accident driver's visible fatigue. They consulted the second 
motorcoach driver who was aware of the driver's lack of sleep, yet deferred to the 
accident bus driver's judgment that he was "okay to drive." Passengers described the 
driver as consistently drifting onto the rumble strips of the right shoulder before 
redirecting the motorcoach onto the roadway and once almost hitting a parked truck. The 
driver denied falling asleep at the time of the accident. He stated that he had the habit of 
stretching; rubbing his head, chin, and neck; and squirming in his seat when driving. 

     The onset of sleep is subtle and may not be apparent to the individual experiencing the 
first stage of sleep. Research on sleep deprivation has concluded that the absence of 
behavioral and subjective indicators of sleepiness is not always an accurate reflection of 
the physiological state of sleepiness, the Safety Board said. Individuals can often mask 
symptoms of sleepiness and even compensate for impaired performance for discrete 
periods of time. In its report, the Safety Board emphasized that is it essential for 
transportation companies to make sure that safety-sensitive employees, including drivers 
and operators understand the hazards of fatigue and recognize when they or fellow 
employees are fatigued. 

     The prevention of future accidents requires measures to promote drivers' acceptance 
of personal responsibility for their off-duty actions that are beyond the purview of their 
employers and emphasis on personal responsibility to be fit for duty included in the 
training given by motor carriers, the Safety Board said. The training should emphasize 
that drivers need to use discretion in planning their off-duty activities, to obtain adequate 
sleep, and be responsible for recognizing and reporting fatigue in their fellow drivers. 
Failing to report an on-duty driver who is severely fatigued is no different from failing to 
report an on-duty driver who has knowingly been drinking or using drugs, investigators 
said. 

     As part of its oversight program, the motorcoach company contracted with another 
company to operate a complaint and compliment tracking service but no calls were made 
regarding the accident bus just prior to the accident. The call number was displayed on 
the exterior of the bus, however, the number was not displayed on the inside of the bus 
for passengers who might have safety concerns about their driver. 

     After the accident, the passengers said they were concerned about the driver and 
thought an emergency number posted inside the bus might have helped. As a result, the 
NTSB recommended that the Federal Motor Carrier Safety Administration require the 
posting of an emergency telephone number on the interior of motorcoaches for 
passengers to call in the event of an emergency with the drivers. In the interim, the Safety 
Board urged companies to voluntarily provide a means inside the bus, such as an 
emergency contact number for passengers to report dangerous situations. The NTSB also 
urged motorcoach companies to evaluate all calls reporting dangerous driver behavior 
immediately upon receiving them and establish a method to reach the driver so it can 
evaluate the driver's fitness for duty and take appropriate countermeasures, if necessary. 

For the complete accident report, visit the NTSB Web site at this address: 
http://www.ntsb.gov/publictn/2004/HAR0403.pdf