Sleep apnea, fatigue and a poor traffic management plan combined to cause a fatal 2016 collision between a motorcoach and tractor-trailer truck near Palm Springs, California, according to the National Transportation Safety Board (NTSB).

The driver and 12 passengersof the motorcoach were killed on October 23, 2016 when the speeding vehicle crashed into a stopped truck on Interstate 10 in the early-morning darkness. The truck and other traffic had been stopped on the highway by police for utility work. When traffic resumed, the truck did not move. The motorcoach struck the rear of the truck two minutes later, intruding about 13 feet into the truck trailer and pushing it 71 feet forward.

The NTSB found that the California Department of Transportation had an inadequate transportation management plan for stopping highway traffic near utility work, which resulted in a hazardous situation in which law enforcement did not detect the truck’s lack of movement following the traffic break and did not provide any advance warning to the bus driver of the potential for stopped traffic ahead.

Obesity, sleep apnea, untreated diabetes were factors

Additionally, the NTSB determined the truck driver did not resume driving after the traffic stoppage because he most likely fell asleep due to fatigue related to his undiagnosed, moderate-to-severe obstructive sleep apnea. Despite the fact the truck driver was severely obese and at a very high risk for obstructive sleep apnea, he had not been tested for the condition. And although the Federal Motor Carrier Safety Administration Medical Review Board has developed guidance for screening for obstructive sleep apnea, the FMCSA has not disseminated this guidance to the medical examiners it certifies to perform commercial driver’s license medical examinations.

The NTSB’s investigation also revealed the bus driver had untreated diabetes, but the FMCSA-certified medical examiner did not diagnose the bus driver’s condition or refer the driver for further testing despite a positive glucose urine test during the driver’s medical certificate examination. The NTSB also found that the bus driver did not take actions to avoid the crash because he too was likely fatigued and did not expect to encounter stopped traffic.

Both drivers fatigued

“In this crash, not one but two commercial vehicle drivers – people who drive for a living – were unable to respond appropriately to cues that other motorists acted on,’’ said NTSB Chairman Robert L. Sumwalt. “Federal and state regulators, commercial motor carriers and professional drivers can do better. Given the stakes, they must do better.’’

The board issued eight safety recommendations based upon the findings of the investigation, making two recommendations to the FMCSA, three to the Federal Highway Administration, one to the trucking company, one to three national trucking associations and one to the International Association of Chiefs of Police and the National Sheriffs’ Association.

The abstract of the NTSB’s final report, which includes the findings, probable cause and safety recommendations is available online at https://go.usa.gov/xn22F. The final report will be publicly released in the next several days.

The webcast of the board meeting for this investigation is available for 90 days at http://ntsb.capitolconnection.org/