The five-member board, in a unanimous vote, said the driver, Ophadell Williams, had almost no sleep in the three days leading up to the March 12, 2011, accident except for naps he took on the bus while passengers were inside a Connecticut casino gambling.
The bus was traveling at 78 miles per hour in a 50 mph zone of Interstate 95 while returning to New York's Chinatown when it ran off the road, clattered along a highway guard rail, toppled over and crashed into the support pole for a highway sign. The pole knifed through the bus front to back along the window line, peeling the roof off all the way to the back tires. Besides those killed, 17 other passengers were injured, some severely.
There was no sign that Williams attempted to brake or steer the bus back onto the highway after striking the guard rail, another indication his performance was degraded by fatigue, investigators told the board. They stopped short of saying Williams had fallen asleep.
Williams has pleaded not guilty in New York to charges of manslaughter and criminally negligent homicide. Williams' attorney didn't immediately respond to a request for comment.
"For years, speed has been a factor in accidents. And, we've seen in investigation after investigation, the tragic results of the degraded performance from fatigue. Together, fatigue and speed are an especially lethal combination," NTSB Chairman Deborah Hersman said. She noted that driver fatigue was a factor in seven of the last 19 motor coach accidents the board has investigated.
The circumstances of the New York accident were a "perfect storm" for creating driver fatigue, said Jana Price, an NTSB expert on human performance.
Williams worked mostly overnight shifts, driving to the casino before midnight and returning in the morning. On his days off, he would switch to a nighttime sleep schedule, a transition that creates a feeling of fatigue similar to jetlag, Price said. During the three days prior to the accident, Williams' cellphone and rental car were in almost continuous use during the daytime hours when he had said he was sleeping, investigators said.
The accident occurred at 5:38 a.m., during a time of day known as the circadian trough when the human body's responses to light and darkness create a natural craving for sleep.
The board has previously expressed concern about the prevalence of operator fatigue in all modes of transportation, including the motor coach industry, which transports more than 700 million passengers a year in the U.S. - roughly the same as the domestic airlines.
Federal regulators shutdown the bus operator, World Wide Tours of Greater New York, after the accident for safety violations. Williams had not turned in any driver's logs while working for the company as required by federal safety regulations, yet World Wide took no action, investigators said. He had been being fired by two previous employers and had 18 suspensions of his driving privileges over two decades when he was hired by World Wide.
The board recommended requiring bus companies to obtain the previous 10 years of driving records for bus drivers they are considering hiring, rather than the currently required three years.
After World Wide was shut down, the company's employees, buses and other assets were transferred to a closely related company with similar ownership, Great Escapes, investigators said. That company continues to operate, they said.
Prior to the accident, World Wide tried to get hired to transport troops, but was rejected after a safety inspection by the Defense Department. However, the Federal Motor Carrier Safety Administration conducted several inspections of the company over a number of years and had approved the carrier for the transportation of passengers.
"Something seems to be badly broken," board member Robert Sumwalt said, when one government agency says a company isn't fit to carry troops, but another says they are fit to carry passengers.
The accident might have been prevented, or its severity lessened, if the bus hadn't been speeding, investigators said. The board also recommended federal regulators require advanced speed limiting devices on newly-manufactured heavy trucks and buses.
The New York accident, and other fatal accidents in New Jersey and Virginia last spring, sparked an investigation by the Federal Motor Carrier Safety Administration into the safety of curbside bus operators. Last week, government safety officials swooped down on more than two dozen curbside bus operations that mostly ferry passengers in the busy East Coast transportation corridor between New York and Florida, closing them for safety violations in the largest single federal crackdown on the industry.
National Transportation Safety Board
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