The Board found that the driver's state of fatigue affected his awareness of his vehicle's excessive speed and lane position on a downhill mountain grade of a rural secondary road. Contributing to the accident's severity was the lack of an adequate motorcoach occupant protection system, which the NTSB said is primarily due to the National Highway Traffic Safety Administration's delay in developing and promulgating standards to enhance the protection of motorcoach passengers.
“This tragic accident was entirely preventable,” said Acting Chairman Mark Rosenker. “More importantly, it shines a spotlight on the need for all motor vehicle operators to take responsibility for their physical fitness before they get behind the wheel.”
The NTSB’s investigation identified the following major safety issues: driver fatigue, excessive vehicle speed, hours-of-service violations, motor carrier trip planning, motorcoach occupant protection, and emergency medical notification and response with regard to large motorcoaches traveling on rural roads.
As a result of this accident, the NTSB made eight recommendations to federal and state government agencies, trade associations and the motorcoach operator. Among the most significant are the recommendations to the Federal Highway Administration, the American Association of State Highway and Transportation Officials, and the National Association of State Emergency Medical Services Officials to work together to develop and implement criteria based on traffic patterns, passenger volume, and bus types that can be used to assess the risks of rural travel by large buses.
The NTSB also reiterated one recommendation and reclassified four recommendations to modal agencies of the U.S. Department of Transportation that incorporate two items on the NTSB’s Most Wanted List of Transportation Safety Improvements:
- Enhance Protection for Motorcoach Passengers (National Highway Transportation Safety Administration)
- Require On-board Electronic Recorders (Federal Motor Carrier Safety Administration)