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Highway accident report

HIGHWAY ACCIDENT REPORT
MOTORCOACH RUN-OFF-THE-ROAD
ACCIDENT
NEW ORLEANS, LOUISIANA
MAY 9, 1999

this page intentionally left blank THESE CORRECTIONS ARE INCLUDED
IN THIS VERSION OF THE PUBLISHED REPORT:
HIGHWAY ACCIDENT REPORT NTSB/HAR-01/01 (PB2001-916201) MOTORCOACH RUN-OFF-THE-ROAD NEW ORLEANS, LOUISIANA Page 50 has been updated to correct footnote reference number 145 for the Driver Program Unit, Oregon Department of Transportation, electronic-mail correspondence, May 2001. THESE CORRECTIONS ARE INCLUDED
IN THIS VERSION OF THE PUBLISHED REPORT:
this page intentionally left blank Highway Accident Report
Motorcoach Run-Off-The-Road
Accident
New Orleans, Louisiana
May 9, 1999

NTSB/HAR-01/01
PB2001-916201 National Transportation Safety Board
Notation 7381

490 L'Enfant Plaza, S.W.
Adopted August 28, 2001
Washington, D.C. 20594
National Transportation Safety Board. 2001. Motorcoach Run-off-the-Road Accident, New Orleans,
Louisiana, May 9, 1999.
Highway Accident Report NTSB/HAR-01/01. Washington, DC.
Abstract: On May 9, 1999, about 9:00 a.m., a 1997 Motor Coach Industries 55-passenger motorcoach,
operated by Custom Bus Charters, Incorporated, was traveling eastbound on Interstate 610 in New
Orleans, Louisiana. The bus, carrying 43 passengers, was en route from La Place, Louisiana, to a casino
approximately 80 miles away in Bay St. Louis, Mississippi. As the bus approached milepost 1.6, it
departed the right side of the highway, crossed the shoulder, and went onto the grassy side slope alongside
the shoulder. The bus continued on the side slope, struck the terminal end of a guardrail, traveled through a
chain-link fence, vaulted over a paved golf cart path, collided with the far side of a dirt embankment, and
then bounced and slid forward upright to its final resting position. Twenty-two passengers were killed, the
busdriver and 15 passengers received serious injuries, and 5 passengers received minor injuries.
The following major safety issues were identified in this accident: Inadequacy of the medical certification process, including the current Federal regulations.
Absence of a mechanism for identifying drivers who have tested positive for drugs.
Lack of Federal regulations or standards regarding passive and active occupant protectionsystems on large buses sold or operated in the United States.
Degraded condition of the guardrail posts along the interstate at the accident site.
As a result of this accident investigation, the Safety Board makes recommendations to the Federal MotorCarrier Safety Administration, the American Association of Motor Vehicle Administrators, the NationalConference of State Legislatures, the American Association of State Highway and TransportationOfficials, and the State of Louisiana Department of Transportation and Development. In addition, theSafety Board is reiterating recommendations from its 1999 bus crashworthiness special investigationreport to the National Highway Traffic Safety Administration.
The National Transportation Safety Board is an independent Federal agency dedicated to promoting aviation, railroad, highway, marine,pipeline, and hazardous materials safety. Established in 1967, the agency is mandated by Congress through the Independent Safety BoardAct of 1974 to investigate transportation accidents, determine the probable causes of the accidents, issue safety recommendations, studytransportation safety issues, and evaluate the safety effectiveness of government agencies involved in transportation. The Safety Boardmakes public its actions and decisions through accident reports, safety studies, special investigation reports, safety recommendations, andstatistical reviews.
Recent publications are available in their entirety on the Web at <http://www.ntsb.gov>. Other information about available publications alsomay be obtained from the Web site or by contacting: National Transportation Safety Board
Public Inquiries Section, RE-51
490 L'Enfant Plaza, S.W.
Washington, D.C. 20594
(800) 877-6799 or (202) 314-6551

Safety Board publications may be purchased, by individual copy or by subscription, from the National Technical Information Service. To
purchase this publication, order report number PB2001-916201 from:
National Technical Information Service
5285 Port Royal Road
Springfield, Virginia 22161
(800) 553-6847 or (703) 605-6000

The Independent Safety Board Act, as codified at 49 U.S.C. Section 1154(b), precludes the admission into evidence or use of Board reportsrelated to an incident or accident in a civil action for damages resulting from a matter mentioned in the report. Highway Accident Report
Highway Accident Report
Highway Accident Report
Acronyms and Abbreviations
AAAM -- Association for the Advancement of Automotive MedicineAAMVA -- American Association of Motor Vehicle AdministratorsAASHTO -- American Association of State Highway and Transportation OfficialsAME – aviation medical examinerANPRM -- advance notice of proposed rulemakingBCT -- breakaway cable terminalC/TPA -- consortium or third party administratorCDL -- commercial driver's licenseCFR -- Code of Federal RegulationsCSS -- Consolidated Safety ServicesCustom -- Custom Bus Charters, IncorporatedCVSA -- Commercial Vehicle Safety AllianceDER -- designated employee representativeDMV -- Driver and Motor Vehicle Services DivisionDOT -- U.S. Department of TransportationDOTD -- State of Louisiana Department of Transportation and DevelopmentDVLA -- Driver and Vehicle Licensing AgencyECM -- electronic control moduleEEG -- electroencephalographEMS -- emergency medical serviceEMT -- emergency medical technicianFAA -- Federal Aviation AdministrationFHWA -- Federal Highway AdministrationFMCSA -- Federal Motor Carrier Safety AdministrationFMCSRs -- Federal Motor Carrier Safety RegulationsI-610 -- Interstate 610MCI -- Motor Coach IndustriesMCSAP -- Motor Carrier Safety Assistance ProgramMP -- milepostMRO -- medical review officerMTMC -- Military Traffic Management CommandNBIS -- National Bridge Inspection Standards Acronyms and Abbreviations
Highway Accident Report
NHTSA -- National Highway Traffic Safety AdministrationNOFD -- New Orleans Fire DepartmentNOPD -- New Orleans Police DepartmentNPRM -- notice of proposed rulemakingNYDMV -- New York Department of Motor VehiclesOMC -- Office of Motor CarriersOMCRS -- Office of Motor Carrier Research and StandardsPCP -- phencyclidineSAP -- substance abuse professionalSODA -- Statement of Demonstrated AbilitySPE -- Skill Performance EvaluationTEA-21 -- Transportation Equity Act for the 21st CenturyTHC -- tetrahydrocannabinolTHC-COOH -- tetrahydrocannabinol carboxylic acidU.S.C. -- United States CodeUSFS -- U.S. Department of Agriculture Forest Service Products Laboratory Highway Accident Report
On May 9, 1999, about 9:00 a.m., a 1997 Motor Coach Industries 55-passenger motorcoach, operated by Custom Bus Charters, Incorporated, was traveling eastbound onInterstate 610 in New Orleans, Louisiana. The bus, carrying 43 passengers, was en routefrom La Place, Louisiana, to a casino approximately 80 miles away in Bay St. Louis,Mississippi. As the bus approached milepost 1.6, it departed the right side of the highway,crossed the shoulder, and went onto the grassy side slope alongside the shoulder. The buscontinued on the side slope, struck the terminal end of a guardrail, traveled through achain-link fence, vaulted over a paved golf cart path, collided with the far side of a dirtembankment, and then bounced and slid forward upright to its final resting position.
Twenty-two passengers were killed, the busdriver and 15 passengers received seriousinjuries, and 6 passengers received minor injuries.
The ensuing investigation established that the 46-year-old driver possessed a current commercial driver's license and medical certificate, but suffered from severallife-threatening medical conditions of the kidneys and heart. A witness riding in a vanbehind the bus stated that before the accident, she saw the bus drifting from the left lane tothe center lane, then back to the left lane, before finally crossing the center and right lanesand departing the right side of the road. These observations corresponded with thestatements of a passenger, who saw the busdriver "slouch down" as if reaching for a sodaand then upright himself before slouching down again. The next thing this passengerremembered was waking up in the hospital.
The National Transportation Safety Board determines that the probable cause of this accident was the driver's incapacitation due to his severe medical conditions and thefailure of the medical certification process to detect and remove the driver from service.
Other factors that may have had a role in the accident were the driver's fatigue and thedriver's use of marijuana and a sedating antihistamine.
The following major safety issues were identified in this accident: Inadequacy of the medical certification process, including the current Federalregulations.
Absence of a mechanism for identifying drivers who have tested positive fordrugs.
Lack of Federal regulations or standards regarding passive and active occupantprotection systems on large buses sold or operated in the United States.
Degraded condition of the guardrail posts along the interstate at the accidentsite.
Highway Accident Report
As a result of this accident investigation, the Safety Board makes recommendations to the Federal Motor Carrier Safety Administration, the AmericanAssociation of Motor Vehicle Administrators, the National Conference of StateLegislatures, the American Association of State Highway and Transportation Officials,and the State of Louisiana Department of Transportation and Development. In addition,the Safety Board is reiterating recommendations from its 1999 bus crashworthinessspecial investigation report to the National Highway Traffic Safety Administration.
Highway Accident Report
About 9:00 a.m. on May 9, 1999, a 1997 Motor Coach Industries (MCI), model 102DL3, 55-passenger motorcoach, operated by Custom Bus Charters, Incorporated(Custom), was traveling eastbound on Interstate 610 (I-610) in New Orleans, Louisiana.
The bus, carrying 43 passengers, was en route from La Place, Louisiana, to a casino about80 miles away in Bay St. Louis, Mississippi (figure 1). Visibility was good and thepavement, dry. Figure 1. Accident area (map by Geographic Data Technology, Inc.).
As the bus approached milepost (MP) 1.6, it departed the right side of the highway, crossed the shoulder, and went onto the grassy side slope alongside the shoulder. The buscontinued on the side slope, struck the terminal end of a guardrail, traveled through achain-link fence, vaulted over a paved golf cart path, collided with the far side of a dirtembankment, and then bounced and slid forward upright to its final resting position (seefigure 2). Twenty-two passengers were killed; the busdriver and 15 passengers receivedserious injuries, and 6 passengers had minor injuries. The injured were transported to fourarea hospitals.


Highway Accident Report
Figure 2. Rescue workers attempt to stabilize the bus in its final resting position.
Two witnesses in a van traveling eastbound in the center lane of I-610 told National Transportation Safety Board investigators that before the accident they saw asmall green car in the center lane about 300 feet in front of them and a tour bus in the leftlane beside the green car. They said that the bus drifted towards the center lane and almosthit the small car but then drifted back to the middle of the left lane. After that, the smallcar then slowed until it was no longer beside the bus.
At this time, according to one witness in the van, the bus changed lanes without appearing to be drifting, crossed the center lane, and continued off the side of the road.
She said that the bus was not out of control, did not have its brakes applied, and did notwaiver or swerve in any direction. She said that it continued on a direct path and crashedinto the embankment, then "flew through the air several feet and landed against a fencewhich was on the side of the interstate." She added that she had not seen any vehicle infront of the bus before the lane change. The other witness in the van said that after the busleft the roadway, he pulled over to help. By this time, other vehicles had also stopped tohelp.
At the time of the accident, New Orleans Police Department (NOPD) unit 303A was on routine patrol traveling westbound on I-610, when the officer driving noticed a redand white bus leaning against the chain-link fence on the eastbound right shoulder. Seeing Highway Accident Report
that the front end of the bus was heavily damaged, the officer pulled over onto the centeremergency strip and notified his dispatcher of the accident at 9:02 a.m.
The NOPD officer and the witness, who had previously pulled over his van, attempted to enter the bus through the left side. The witness stated that they tried first tobreak the side windows but when they could not, attempted unsuccessfully to enter the busthrough other openings. The witness stated that he then moved toward the third or fourthwindow on the right side of the bus and saw an elderly woman hanging out of a sidewindow with one of her feet trapped in the vehicle. When the witness could not removethe woman through the window, he tried to alleviate the pressure on her trapped foot bysupporting her weight. He said that while supporting this passenger, he realized that hewas standing on top of a body, which was underneath a large piece of shattered glass.
After another rescuer arrived and pulled the body away from the side of the bus, thewitness returned to supporting the woman. As he supported her, he peered into the vehicleand saw about four passengers on top of each other near the right side windows.
By 9:10 a.m., fire and emergency medical service (EMS) personnel began arriving.
The emergency medical technicians (EMTs) who arrived first at the accident scene toldSafety Board investigators that they found 10 people on the ground outside of the bus,including the busdriver. The EMTs said that other victims were still in the bus and that thewindows on the left side were still intact. The emergency responders entered the bus bybreaking the left-side windows and removed the passengers.
When the NOPD officer in unit 303A notified his dispatcher of the accident at 9:02 a.m., he requested emergency medical assistance. The NOPD dispatcher then initiated theincident emergency response and dispatched EMS personnel. At the same time, thedispatcher upgraded the incident from a priority one to a priority two incident, indicatingthat it was a mass casualty event. By 9:03 a.m., two other NOPD units were en route. At9:04 a.m., the New Orleans Fire Department (NOFD) was notified. At 9:10 a.m., EMScontacted the NOPD dispatcher to request more EMS assistance. The dispatcher notifiedand dispatched additional NOPD and NOFD units to the accident site. By 11:03 a.m., 19fatalities had been confirmed. EMS assistance continued to be dispatched until all of thepassengers and the driver were removed from the scene.
The NOPD cleared the accident scene at 10:51 p.m. In all, the NOPD dispatched approximately 30 personnel, including police officers, supervisory personnel, and publicinformation officers. The NOFD dispatched 1 district chief; 7 fire captains; 4 equipmentoperators; 34 firefighters; and 12 fire units, including fire engines, a ladder truck, and arescue truck to the accident scene. City Park Police officers also assisted with trafficcontrol on the interstate, stabilization of the bus, and scene preservation.
Highway Accident Report
Table 1 is based on the injury criteria of the International Civil Aviation Organization, which the Safety Board uses in accident reports for all transportation modes.
Table 1. Injuries.
*Title 49 Code of Federal Regulations (CFR) 830.2 defines fatal injury as "Any injury which results indeath within 30 days of the accident." It defines serious injury as an injury that "(1) Requires hospitalization for more than 48 hours, commencing within 7 days from the date the injury was received; (2) results in a fracture of any bone (except simple fractures of fingers, toes, or nose); (3) causes severehemorrhages, nerve, or tendon damage; (4) involves any internal organ; or (5) involves second or third degree burns, or any burn affecting more than 5 percent of the body surface." At the time of the accident, the 46-year-old busdriver had a current Louisiana Class B commercial driver's license (CDL)1 with an expiration date of November 7, 1999.
He also had a medical certificate, which was current until August 2000. The driversuffered serious injuries from the crash,2 but was treated and released. In August 1999, thedriver returned to the hospital, where he died of "natural" causes, according to his autopsyreport.
1 A class B CDL allows an individual to drive a single vehicle with a gross vehicle weight rating of 26,001 or more pounds or any such vehicle towing a vehicle not in excess of 10,000 pounds, gross vehicle weight rating (49 Code of Federal Regulations [CFR] 383.91(a)(2)).
2 The driver sustained multiple fractures of his spinal column, a pelvic fracture, and thumb and finger Highway Accident Report
The driver was off duty on May 7 and 8, the 2 days before the day of the accident.
On the afternoon of May 8, the driver underwent scheduled hemodialysis treatment3between 2:55 and 6:35 p.m. According to medical records, he terminated the treatmentearly against medical advice. However, at 8:45 p.m., he returned to the hospital byambulance because he was suffering from low blood pressure, dizziness, and nausea.4 Hereceived one liter of intravenous fluid and was released at 11 p.m. The busdriver's mother,with whom he lived, stated that he arrived home from the hospital about 11:30 p.m. Shelater heard him wake up about 5:30 a.m. Safety Board investigators were unable to obtainadditional details from the busdriver himself because of the seriousness of his injuries andhis refusal to be interviewed.
According to the busdriver's log entry for May 9, he conducted a pretrip inspection at 6:30 a.m. and left the bus terminal in Harvey, Louisiana, about 7:00 a.m. He then droveapproximately 30 miles to La Place for a scheduled 8:00 a.m. pickup time at theDelchamps Grocery Store parking lot. Custom officials reported that he then drove toKenner, Louisiana, where he made an unscheduled stop to pick up additional passengers.
According to Custom, the unscheduled stop was agreed upon when the charter left LaPlace. At the time of the accident, the busdriver was en route to his last passenger pickuplocation, which was in east New Orleans, a short distance from the accident site. Thedriver was scheduled to arrive at the casino in Bay St. Louis, Mississippi, at 10:30 a.m.
Toxicological specimens of the driver's blood and urine were obtained by the Safety Board from Charity Hospital, where the driver was transported for emergencymedical treatment after the accident. The specimens were sent to the Civil AeromedicalInstitute of the Federal Aviation Administration (FAA), in Oklahoma City, Oklahoma.
Postaccident analyses of the busdriver's blood and urine specimens detected thefollowing: Blood: 8 (ng/ml, ng/g) tetrahydrocannabinol (THC)
48 (ng/ml, ng/g) tetrahydrocannabinol carboxylic acid (inactive metabolite of THC) 17 (ng/ml, ng/g) diphenhydramine 3 Hemodialysis describes the removal of certain elements from the blood by virtue of the difference in the rates of their diffusion through a semipermeable membrane, for example, by means of a hemodialysis machine or filter. This treatment is frequently used to treat end-stage kidney disease.
4 "Acute complications related to the dialysis procedure itself may severely compromise the quality of life in chronic dialysis patients. A mild degree of hypotension (low blood pressure) is normal in dialysis, but severe degrees may be disabling. Muscle cramps, chest or back pain, hypoxemia, fever, nausea, seizures, or cardiac arrhythmias may occur. In addition, mechanical problems related to dialysis machines, cartridges,and water purifiers may occur." From "Morbidity and Mortality of Dialysis," Consensus Statement No. 93, National Institutes of Health Consensus Development Conference, Bethesda, Maryland, November 1 through 3, 1993.
Highway Accident Report
Urine: 193 (ng/ml, ng/g) tetrahydrocannabinol carboxylic acid5
Phenylpropanolamine Medical notes indicated that a 25-milligram oral dose of diphenhydramine had been given to the driver during hemodialysis at 3:30 p.m. on the day before the accident.
Diphenhydramine is available over the counter as a sleep aid and is contained in manyover-the-counter cold and allergy preparations, often in combination with a decongestant;it is also frequently used to control itching in dialysis patients. Diphenhydramine has bothsedating and performance-impairing effects, and studies indicate that individuals may feelfine while on the medication but still be impaired in their driving performance.6 Phenylpropanolamine is available over the counter in numerous medications, frequently in combination with an antihistamine. It is often used as a stimulant (similar tocaffeine) and can interfere with normal sleep. Recently, phenylpropanolamine has beenthe subject of Federal Drug Administration action to withdraw it from the market becauseof a very small but measurable risk of stroke, primarily in women who use it for weightloss.7 Metoprolol is a medication used to control blood pressure and other heart-related conditions. Although it is not typically regarded as impairing, it tends to reduce the heart'sresponse to stress. This tendency can increase the possibility of loss of consciousness withdehydration, as it prevents the heart rate from substantially increasing when bloodpressure falls. The driver had been prescribed this medication.
Small amounts of THC (the active substance in marijuana) and larger amounts of tetrahydrocannabinol carboxylic acid were detected in the driver's blood collected morethan an hour after the accident. Short-term effects of marijuana use include problems withmemory and learning; distorted perception; difficulty in thinking and problem-solving;lethargy; loss of coordination; and increased heart rate, anxiety, and panic attacks.8 Although the 46-year-old busdriver had a current medical certificate, which certified him as physically fit to drive a commercial vehicle, he suffered from several 5 The quantities listed for tetrahydrocannabinol exceed the reporting levels specified by the U.S.
Department of Transportation in 49 CFR 40.87.
6 J.M. Weiler, J.R. Bloomfield, G.G. Woodworth, A.R. Grant, T.A. Layton, T.L. Brown, D.R.
McKenzie, T.W. Baker, and G.S. Watson, "Effects of Fexofenadine, Diphenhydramine, and Alcohol on Driving Performance: A Randomized, Placebo-Controlled Trial in the Iowa Driving Simulator," Annals ofInternal Medicine, Vol. 132, No. 5 (2000): 354-363.
7 Information obtained on May 9, 2001, from the Center for Drug Evaluation and Research, Federal Drug Administration, Web site <http://www.fda.gov/cder/drug/infopage/ppa/default.htm>.
8 Information obtained on May 9, 2001, from the National Institute on Drug Abuse, National Institutes of Health, Web site <http://www.nida.nih.gov/Infofax/marijuana.html>.
Highway Accident Report
serious medical conditions. Two years before the accident, the busdriver was diagnosedwith dilated cardiomyopathy.9 This condition resulted in repeated admissions to thehospital for congestive heart failure.10 During hospitalizations in December 1998 andJanuary 1999, he experienced several short asymptomatic episodes of ventriculartachycardia.11 Then, 2 months before the accident, the driver was admitted to the hospitalfor congestive heart failure and was subsequently placed on intravenous dobutamine12therapy three times a week. In addition, the driver was diagnosed with kidney failure inJuly 1998 and had been scheduled to receive hemodialysis three times a week sinceDecember 1998. According to his medical records, during 5 months of dialysis treatment,he ended treatment prematurely on two occasions, and, on at least four occasions, did notkeep appointments for scheduled treatment. Hospital and clinic records indicated thatdoctors and other medical staff were aware of the driver's profession. (For further details,see appendix B.) A Custom representative stated that the company was aware of the driver's kidney problems and hemodialysis treatments but had no knowledge of his heart condition. Theyhad adjusted the driver's work schedule to accommodate his medical treatments.
As a result of the heart and kidney problems the driver had at the time of the accident, he was scheduled for hemodialysis treatment every Tuesday, Thursday, andSaturday (4 hours each day) and for outpatient intravenous dobutamine therapy everyMonday, Wednesday, and Friday (3 hours each day).
At the time he was hired by Custom in June 1997, the busdriver held a current Louisiana medical certificate, which was due to expire April 20, 1999. In March 1998,while on a trip to Shreveport, Louisiana, the driver contacted the dispatcher and advisedthat he was unable to complete the trip. He checked himself into a hospital, complainingof severe shortness of breath and sweating while moving luggage. He was transferred toOchsner Hospital in New Orleans, where he was diagnosed with congestive heart failure.
He was admitted to a hospital again in July 1998 for "progressive shortness of breath for 3to 4 days." Hospital records state, "The patient is on chronic medical therapy for thisproblem but continues to work. He gets breathless at low levels of activity…." As a resultof his inability to complete a trip due to medical reasons and because of subsequent 9 Dilated cardiomyopathy is a disease of the heart muscle that leads to impaired heart function, enlargement of the heart, and congestive heart failure and is often associated with abnormal heart rhythms.
The disease is generally progressive, with death usually occurring within 2 years of the onset of symptoms.
10 Inability of the heart to keep up with the demands on it and, specifically, the failure of the heart to pump blood with normal efficiency. When this occurs, the heart is unable to provide adequate blood flow to other organs such as the brain, liver, and kidneys. In the 2 years before the accident, the driver was diagnosed with congestive heart failure during five separate hospital admissions.
11 An abnormal heart rhythm that is rapid, regular, and originates from an area of the ventricle, the lower chamber of the heart. Ventricular tachycardias are life-threatening arrhythmias most commonly associated with heart attacks or the scarring of the heart muscle from a previous heart attack.
12 Dobutamine is often administered intravenously to patients with severe congestive heart failure to temporarily improve heart function.
Highway Accident Report
hospital admissions, Custom had the driver submit to a medical examination, as isrequired under Federal regulations.13 The busdriver scheduled a commercial driver medical examination on August 19, 1998. In a postaccident interview, the physician who performed the examination informedSafety Board investigators that the driver initially indicated that he had no heart problems.
She said that when the driver told her that he was taking warfarin, hydralazine, Lasix(furosemide), metoprolol, and Bumex (bumetanide),14 she asked again whether he had anyheart problems, at which point he said that he had a history of high blood pressure andcongestive heart failure.
The physician told Safety Board investigators that she had performed commercial driver examinations before, "but not every day." She stated that she had a page withlimited guidance, including the regulations that covered the performance of theexamination. She noted the regulatory restrictions regarding "no current clinical diagnosisof myocardial infarction, angina pectoris, coronary insufficiency, thrombosis, or any othercardiovascular disease of a variety known to be accompanied by syncope, dyspnea,collapse, or congestive cardiac failure," but stated that at the time of the examination, thedriver exhibited no current clinical evidence of congestive heart failure. Therefore, shebelieved that the regulations did not exclude him from operating a commercial vehicle.
The examiner signed the busdriver's medical certificate indicating that he was physicallyqualified to drive a commercial vehicle.
The examiner informed Safety Board investigators that the driver had a trace amount of albumin in his urine,15 but that he had related no history of kidney disease. Shesaid she recommended to the driver that he undergo an evaluation with his primary caredoctor. The regulations themselves do not specifically address kidney disease, althoughexaminer instructions following 49 Code of Federal Regulations (CFR) 391.43(f) do statethat a urinalysis is required. The instructions that accompany the regulations also statethat: Acute infections of the genitourinary tract, as defined by local and State publichealth laws, indications from urinalysis of uncontrolled diabetes, symptomaticalbumin-urea in the urine, or other findings indicative of health conditions likelyto interfere with the control and safe operation of a commercial motor vehicle,will disqualify an applicant from operating a motor vehicle.
The examiner commented to Safety Board investigators that very little available guidance exists regarding cardiovascular issues for individual physicians, who must 13 Title 49 CFR 391.45 states that persons must be medically examined and certified as physically qualified to operate a commercial motor vehicle if their ability to perform normal duties has been impaired by a physical or mental injury or disease.
14 Warfarin is an anticoagulant used to prevent clotting. Hydralazine is an antihypertensive used to treat high blood pressure. Furosemide and bumetanide are diuretics often used to treat congestive heart failure.
15 The presence of albumin in the urine is a possible sign of kidney disease.
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frequently rely upon their own judgment to determine whether a condition isdisqualifying.
The busdriver's employment records showed the following information: May 1976–March 1989: The Regional Transit Authority employed the driver as a
New Orleans public transit busdriver. He tested positive for marijuana in July 1988. Hesubsequently enrolled in, and successfully completed, a drug rehabilitation program. Hewas fired after a second positive drug test (for marijuana) in March 1989.
1988–1997: The driver was employed part-time by Turner's Bus Service as a
charter busdriver.
April 1992–July 1996: The driver worked for Westside Bus Service as a public
transit busdriver. He was fired because of a positive drug test (for marijuana).
October 1996–April 1997: The driver worked for Hertz Corporation as a shuttle
busdriver. He resigned following his third property damage accident.
April 1997: The driver applied to Greyhound Lines, Inc., for a busdriver position.
He underwent physical examination and preemployment drug screening and testedpositive for cocaine. He was rejected for employment.
June 1997–May 1999: The driver was employed by Custom as a busdriver. He
underwent a preemployment drug test and three random drug tests during his tenure withnegative results.
When the New Orleans driver applied for the position at Custom, he listed his former positions with Hertz Car Rental and Turner's Bus Service but did not mention thepositions held with the Regional Transit Authority and with Westside Bus Service, wherehe had been fired for testing positive for marijuana. He explained the gaps in hisemployment record by stating that he was a musician in a brass band during those times.
Custom sent authorized requests for information to both Hertz Car Rental and Turner'sBus Service but did not receive a response from either company.
Custom officials told Safety Board investigators that they considered the busdriver a part-time employee. In addition, they stated that he was thought to be a good driver andhad not generated any customer complaints.
In 1977, the driver was convicted of drug possession, for which he received a suspended 2-year prison sentence. His motor vehicle record showed that between 1994and 1998, he had been involved in three property damage accidents while driving a bus.
He also had three convictions for traffic violations: a speeding violation in July 1996, Highway Accident Report
another speeding violation in August 1997 (the second offense was committed whileoperating a commercial vehicle), and a signs/signals violation in June 1997.
MCI of Pembina, North Dakota, manufactured the 55-passenger motorcoach in November 1996. Its overall length was 45 feet 6.25 inches, and its unladed16 weight wasabout 35,250 pounds. Its center of gravity was 39 inches above the ground.17 Themotorcoach's Detroit Diesel Series 60, 6-cylinder, 400-horsepower diesel engine wasequipped with a DDEC III (Detroit Diesel, electronic control module, commonly referredto as an electronic control module [ECM]).18 This ECM did not contain active data pagesthat would have given a history of preaccident events (for example, speed, rpm, andbraking). The motorcoach was equipped with an Allison model B500R automatictransmission with an integral "vane type" retarder. The motorcoach had a steering axle, adual-wheel drive axle, and a self-steering auxiliary weight-bearing axle, commonlyreferred to as a tag axle.19 All of the wheels were equipped with air brakes.
After the accident, the motorcoach was towed to the city impound lot. Safety Board investigators began inspecting the vehicle the day after the accident and performeda followup inspection on the self-steering tag axle on June 10, 1999.
Data from the ECM revealed that two fault codes were recorded, one involving high engine coolant temperature and the other, high fuel temperature. The data indicatedthat both of these faults occurred at least 1,000 hours before the accident. The data alsoindicated that the engine had a governed speed of 75 mph and had traveled 194,337 miles.
Investigators also removed the electronic control unit from the automatic transmission of the vehicle and examined it. The data extracted did not reveal any faultcodes.20 The master switch for the transmission retarder was found in the "off" position.21 The coach was equipped with an air brake system that provided braking to all three axles and a Bendix DD3 emergency and parking brake system that operated only on thedrive axle. The steering and drive axles had standard clamp-type foundation brakes(S-cam) with brake drums, and the tag axle had disc brakes. All of the brake shoes on thesteering and drive axle were about 3/4 inches thick. The disc brake pads on the tag axlehad been replaced with new pads 4 days before the accident.
16 Weight with no passengers or cargo.
17 As estimated by Motor Coach Industries staff.
18 The ECM's primary function is to control fuel flow to the engine to provide maximum fuel economy and to meet Government emission standards.
19 A tag axle is a load-bearing, nondrive axle, located to the rear of a vehicle's drive axle.
20 A fault code indicates a past or current defect in the transmission system.
21 A transmission retarder provides auxiliary braking forces to a vehicle and is activated when a driver releases his or her foot from the accelerator.
Highway Accident Report
Due to extensive damage to air lines and valves, including the foot valve, the braking system could not be checked by supplying air to the external port and utilizing thefoot valve (brake pedal). Therefore, the air chambers were plumbed directly into anexternal regulated air supply to obtain push rod measurements. All but one push rodmeasurement was within the maximum stroked allowed.22 One push rod was 1/8 inch overthe maximum stroke allowed; based upon push rod travel, it was calculated that the brakescould still produce at least 90 percent of the forces that would be generated by a brake ingood adjustment.23 The motorcoach was equipped with a TRW (Ross) hydraulically assisted power steering system with an integral steering gear box.24 A field examination of the steeringsystem found that the steering wheel was deformed and the steering column displacedrearward. All of the linkages were still in place, but with some deformation. The axle stopswere in place and undamaged. The steering gearbox and steering pump were removed andbench-tested at the manufacturer's site; no defects were discovered.
All six of the motorcoach tires were Bridgestone or Firestone radials, size 315/80R22.5, with highway tread. None of the tires were flat, with air pressure rangingfrom 84 to 100 psi. The inside of the left-front tire had a fresh cut, about 2 inches long; noother defects were noted. The tire tread depths were 5/32 inches or more. Federalregulations require that vehicles be placed out of service when the tire tread depth is lessthan 4/32 inches on the front wheels and less than 2/32 inches on the other wheels.25 I-610 at the accident site has a speed limit of 60 mph, with three eastbound lanes and three westbound lanes, divided by a 32-inch-tall concrete median barrier. All lanes are12 feet wide, with a 9-foot-wide inside shoulder, a 10-foot-wide outside shoulder, and a30-foot-wide grassy side slope. Four-inch-wide and 10-foot-long broken retroflectivepainted white lines, spaced at 25-foot intervals, separate the travel lanes in each direction.
A 6-inch-wide painted solid yellow edge line delineates the inside shoulder, and a6-inch-wide retroflective painted solid white edge line delineates the outside shoulder.
An overpass (bridge) near MP 1.6 accommodates a golf cart path under I-610. The overpass was situated on a 200-foot-long vertical curve with a 1.3-percent grade. The busleft the roadway approximately 180 feet west of the overpass, near the beginning of thetransition to the vertical curve.
22 Commercial Vehicle Safety Alliance, North American Standard Out-of-Service Criteria (Bethesda, Maryland: CVSA, 2001).
23 R.B. Heusser, Heavy Truck Deceleration Rates as a Function of Brake Adjustment, Society of Automotive Engineers technical report 910126, 1991.
24 The term integral refers to the rotary control valve, hydraulic cylinder, and mechanical gears being located inside the gearbox housing, as opposed to being mounted in three separate locations.
25 Title 49 CFR 393.75 (b) and (c).
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Gouge marks could be seen on the embankment on the far side of the golf cart path. A set of compressed grass tire marks was found on the grassy side slope. The angleof departure of the tire marks was between 6 and 7 degrees. At the time of the accident, theroadway and side slope were dry. (See figure 3.) Figure 3. Departure angle of the bus, based on the 6- to 7-degree tire
marks located on the grassy side slope of the roadway.
A blocked-out W-beam (strong post) guardrail (barrier) system was attached to the bridge rail on the right side of the roadway. The W-beam guardrail, which is considered acomponent of the highway bridge, is the most common type of barrier system in use today,according to the American Association of State Highway and Transportation Officials(AASHTO). Crash tests have shown that this system can redirect vehicles in the 1,760- to4,400-pound range.26 During testing, it has also redirected a 4,620-pound van, traveling at57 mph and impacting at a 21-degree angle. This barrier system is not designed to restrictencroachment for heavier vehicles or vehicles with a higher center of gravity, such asmotorcoaches and heavy trucks. 27 The guardrail system at the accident site was upgraded during a highway restoration project on I-610 in 1989. The system consisted of galvanized steel W-beamguardrail elements, supported by 6-foot-long wooden posts, 26-inch-long timber spacers,and a breakaway cable terminal (BCT) end assembly. The guardrail was approximately 27inches high, with wooden posts spaced 6.25 feet apart. The end treatments of the guardrailwere designed to prevent a passenger vehicle from becoming impaled on the guardrail,and the BCT ends were designed to fail at impact. The BCT had two endposts that were 26 Vehicles are commonly tested using a speed of 60 mph and an approach angle of 25 degrees.
(American Association of State Highway and Traffic Officials, Roadside Design Guide [Washington, DC: 1996] 5-10).
27 In tests to establish upper performance limits, this barrier system failed in a van and a school bus test (approach angles of 25 degrees) due to the rolling of the respective vehicles (Roadside Design Guide, 5-10).


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attached to galvanized steel footings and designed to shear off when hit by a small truck orautomobile, with the cable attached to the rail and footing designed to slow down thevehicle. The wooden posts were pretreated with preservatives before installation.
According to the AASHTO Roadside Design Guide,28 preservative-treated wooden posts,such as the ones used at the accident site, require almost no maintenance, except for anoccasional cleaning and treatment.
During the collision sequence, the bus collided with the guardrail near the BCT, fractured 11 wooden posts, and damaged a 33-foot-long section of W-beam guardrail. (Seefigure 4.) Figure 4. Fractured wooden posts at accident site.
During the investigation, Safety Board investigators found that some of the wooden posts were infested with termites. Due to the extensive collision damage to theposts, the exact number of posts with termite damage could not be determined. Portions ofposts, with and without termite damage, were sent to the U.S. Department of AgricultureForest Service Products Laboratory (USFS) for evaluation. According to the USFS report,two of the four samples had considerable termite damage, with a clear indication offeeding galleries, excrement, and soil. The USFS report noted that material suffering such 28 Roadside Design Guide, 5-17.
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severe attack from termites would have had considerably lower mechanical properties,including shear strength. It stated that a "large portion of the original woody material hasbeen removed reducing the post's ability to resist impact loads." Safety Board investigators then conducted 16 random inspections of guardrail systems constructed with wooden posts along the interstate system near New Orleans.
Evidence of insect damage was observed at 3 of the 16 locations (19 percent) inspected.
Several of the wooden posts at the three sites exhibited termite damage.
The State of Louisiana Department of Transportation and Development (DOTD) replaced 11 wooden posts and spacers, the 33-foot-long section of W-beam guardrail, andthe BCT end assembly damaged by the bus. Since the postaccident repairs to the guardrailsystem, DOTD has replaced five additional (nearby or adjacent) wooden posts that werenot damaged in the accident but showed signs of insect infestation and reduced impactresistance.
Guardrail Inspection Programs
Federal. As noted previously, the guardrails involved in this accident were a
component of a bridge overpass. The Federal Highway Administration (FHWA) NationalBridge Inspection Standards (NBIS) constitute the Federal standards for bridge structuresand guardrail designs. The States use FHWA standards for their bridge inspectionprograms but set their own maintenance policies. Federal standards do not address theinspection of guardrails apart from the bridge structures. Further, Federal standards do notaddress the inspection of guardrail posts (wooden or metal) or the effects of insectinfestation or corrosion on a guardrail system.
Louisiana Department of Transportation and Development. According to
DOTD,29 the State's inspection program follows the guidelines and specifications of theNBIS. DOTD also uses supplemental guidelines for bridge inspections based on theFederal standards.30 DOTD inspects its bridges and associated components, such as any attached superstructures and substructures, including guardrails, as a unit. These bridge structuresare inspected for structural integrity as well as for major safety defects. DOTD does notspecifically inspect the guardrail wooden posts and spacer blocks for termite or insectinfestation. The guardrails are inspected during the bridge inspection, as required by theFederal standards, and are noted in the bridge inspection report. Normally, the bridgestructures are inspected every 2 years, or every year if they have any critical safetyfeatures.
DOTD has inspected the bridge at the accident site every 2 years. The DOTD National Bridge Inspection Report for 1995 indicated Very Good Condition—no problem 29 Robert Wegener, Jr., District Maintenance Engineer, DOTD.
30 Texas, Arkansas, Mississippi, Alabama, and Florida also use supplemental guidelines based on the Highway Accident Report
noted; and for 1997, Good Condition—some minor problems. No further guardrail systemexplanation was cited. The DOTD bridge inspection reports do not refer to insect damageto the wooden posts.
Motor Carrier Information
Custom was an interstate, for-hire, carrier of passengers providing service within the continental United States and Canada, operating under the authority of the U.S.
Department of Transportation (DOT). The company began operations in 1990 as alimousine service for the New Orleans area. In 1992, it began charter operations. Customoperated terminals in Harvey, Baton Rouge, and Lafayette, Louisiana, and Council Bluffs,Iowa. At the time of the accident, the company employed 147 workers, including 57full-time drivers and 36 part-time drivers, as well as office and maintenance personnel.
The average age of a Custom driver was 50 years. Custom ceased operations on July 1,1999, for reasons stemming from this accident.31 At the time of the accident, Custom had 45 motorcoaches, 16 shuttle buses, and four 15-passenger vans. The motorcoaches were leased from Financial Services, Inc., ofNorwalk, Connecticut; the average age of the fleet was 2 years. Custom officials reportedthat their business was 80 percent charter service. Custom also ran a shuttle service to andfrom the New Orleans airport and downtown area. Custom operations recorded 3.2million miles traveled from May 1998 to May 1999.
Motor Carrier Oversight
Custom's safety director had previously been a company busdriver. His duties included inspecting the logbooks of both local and long-distance drivers. He alsoconducted new-hire training and in-service training every 6 months for company drivers.
Training topics have included driving a motorcoach, drug and alcohol testing, highwaydriving hazards, pretrip vehicle inspections, and hours-of-service regulations.32 The safetydirector was a State-certified third-party tester33 for CDL training. He said that he usedfive of Custom's most experienced drivers to administer road tests to other drivers.
Custom started its random drug testing program in 1996, in compliance with the Federal Motor Carrier Safety Regulations (FMCSRs), 49 CFR 382. Custom contractedwith MRO Associates to conduct the company's preemployment and random drug testsand to provide the services of a medical review officer (MRO) to analyze the test results.
Company drivers were selected for random testing through a computer-generated program in the MRO's office. The MRO notified Custom's director of operations to advisea driver to report for testing within 3 hours, and the director, in turn, completed a slip to be 31 Kenneth Begovitch, former owner of Customer Bus Charters, Inc.
32 Terrell Walker, Safety Director, Custom Bus Charters, Inc.
33 Entity authorized by the State to administer skills tests to commercial drivers.
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given to that driver. Failing to report within the required 3 hours was considered a refusaland resulted in the driver being terminated. If a driver were operating a charter trip whenhis name came up on the random list, he or she would be given the slip upon returningfrom the trip to report for the test. According to Custom, drivers had no advance warningof a test. Custom officials reported a "no tolerance" policy on positive drug test results,noting that the company terminates drivers who test positive.
According to summary reports from the MRO's office, 1 test out of the 100 administered in 1998 was positive. No refusal determinations34 occurred. Two tests out ofthe 106 administered in 1997 were positive, with both positive results coming frompreemployment drug tests. Again, no refusal determinations occurred.
During its operations, Custom received three FHWA Office of Motor Carriers (OMC)35 compliance reviews.36 These occurred on February 12, 1996; June 1, 1998; andMarch 19, 1999. (See appendix C for information on Federal motor carrier ratingsprocedures.) Custom requested the February 1996 review because it needed a satisfactory rating to pursue a contract with the Military Traffic Management Command (MTMC) totransport military personnel. The subsequent review resulted in a "satisfactory" rating,although deficiencies were found in driver recordkeeping, hours of service, and thecompany's drug and alcohol testing program.
On July 10, 1996, Consolidated Safety Services (CSS), the civilian contract provider for the MTMC, conducted its own compliance review of Custom. The CSSreview rated Custom "unsatisfactory," based on deficiencies in driver recordkeeping,hours of service, and the company's drug and alcohol testing program. (The Federal MotorCarrier Safety Administration [FMCSA] was aware of the CSS review's findings.) During the June 1998 compliance review, inspectors found that one of Custom's drivers had falsified his medical examiner's examination date on the medical form.
Several logbook and hours-of-service violations were also noted in the review, resulting ina "conditional" rating.
34 According to 49 CFR 382.107, there are nine circumstances in which a driver is considered to have refused to submit to a drug test. Included among these are the submission of a specimen verified to be substituted or adulterated and the failure to undergo a medical examination or evaluation as directed by theMRO as part of the verification process.
35 The 1999 Motor Carrier Safety Act separated the OMC from the FHWA and created a new administration called the Federal Motor Carrier Safety Administration (FMCSA). The FMCSA now handles compliance reviews and all other highway commercial transportation safety functions.
36 Title 49 CFR Part 385.3 defines "compliance review" as an on-site examination of motor carrier operations, such as drivers' hours of service, maintenance and inspection, driver qualification, CDL requirements, financial responsibility, accidents, hazardous materials, and other safety and transportation records, to determine whether a motor carrier meets the safety fitness standard.
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The March 1999 compliance review, which also resulted in a conditional rating, was conducted as an enforcement followup to the 1998 review. This review found thatCustom operated a motorcoach that did not comply with local laws, ordinances, andregulations, a critical element in the rating process.37 Another critical element noted in thereview was Custom's high accident rate based on the number of miles traveled during thepast year. In June 1999, the Custom safety director petitioned the FHWA to reconsider therating from the March compliance review. The petition asserted that during thecompliance review, the mileage generated by the shuttle service was omitted in calculatingthe accident rate for the company. The increase from 1.8 million miles traveled to thecorrect figure of 3.2 million miles traveled lowered Custom's accident rate from 2.710 to0.647 per million miles traveled. This rate was below the national average of 1.6 permillion miles for motor carriers. With this modified accident rate, the FHWA changedCustom's overall rating from conditional to satisfactory.
Passenger Compartment Safety Features
The safety features of the accident bus are described in table 2.
Table 2. Passenger Compartment Safety Features.
Side windows (16) 34 inches high, 52 inches wide, All designated as Driver side-8; passenger side-8 separated by 5.5-inch sidewall; emergency exit windows bottom ledge 28.5 inches from floor Front windshield (2 panes) 44.5-inch-wide panes: left-side Each with own visor, glazing—42.5 inches high, separated by 1.5 inches of right-side glazing—47 inches high 14.5 inches high, 90.5 inches wide Positioned 2 inches above Emergency exit hatches (2) 29 inches long, 20 inches wide Passenger seats (55) The motorcoach body sustained massive frontal crush deformation within the driver, stairwell, and forward passenger areas, compromised by front axle upwardintrusion into the floorboard. (See figures 5 and 6.) The dashboard instrument panel,steering wheel, and driver's seat and partition had been crushed downward and rearward. 37 Custom was cited for operating a bus without a current State inspection sticker.


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The forward passenger compartment floorboard had been deformed upward toward theinterior roof in the first three rows. The first four left- and right-side window framessustained damage, and the glazing38 was missing or shattered in most.
Emergency responders removed seats 9 and 10, 13 through 18, 21 and 22, and 25 and 26 to extricate surviving and deceased passengers. (See figure 7 for seat layout.39)Seats 1, 2, 7, and 8 sustained partial separation of the vertical mounting leg of the "T"pedestal at the horizontal base that was attached to the seat track due to vehicle crushformation and intrusion. Some, but not all, seats rearward of the third row sustainedvarying degrees of frame damage. Seatbacks of these seats were deflected forward atdifferent angles due to the accident sequence and to emergency responder activity duringrescue operations.
Figure 5. Body damage to bus, which had been moved from its resting position when
this photograph was taken (photograph by the New Orleans Police Department).
One passenger told Safety Board investigators that she had been sitting on the right side of the bus in seat 12 when the accident occurred. She stated that she did not notice anysudden lane changes and that she did not observe other vehicles in the path of the busbefore or after it left the roadway. She said that she recalled seeing the busdriver "slouchdown," and added, "I thought he was reaching for a coke. He came back up then wentdown again. Next thing I remember is waking up in Charity Hospital." 38 Describes glass or other transparent materials used for windows.
39 Due to a lack of responses to a questionnaire mailed out to survivors of the crash and to the high number of passenger fatalities, a passenger seating chart could not be generated for this accident.


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Figure 6. Driver's side view of the damaged bus (photograph by the New
Orleans Police Department).
A second passenger reported that she was seated in the middle section of the bus in an aisle seat at the time the accident occurred. This passenger recalled that the ride was"nice and peaceful"; she did not recollect any maneuvering of the bus before the accident.
She stated that she was thrown forward and landed on top of another passenger in the aisleand that she next awoke in the hospital.
Another passenger stated that she was seated in the rear section of the bus in seat 48, facing rearward, when the accident occurred. She did not recall the bus making anymaneuvers before the accident. For a time after the accident, she did not recall anything,but then awoke, still in her seat, and found emergency responders helping the injured. Shestated that the emergency responders were "there right away." Accident Reconstruction and Simulation
As part of the Safety Board's investigation, simulations were conducted to determine the estimated speed of the bus before leaving the roadway, its speed beforeimpact with the breakaway cable guardrail, its vault speed over the golf cart pathway, andenergy calculations for the crush of the accident bus on the upward sloping embankment.
To crosscheck these calculations and to determine the occupant kinematics, the accidentwas simulated using a Human Vehicle Environment40 system.
The speed of the bus before it left the roadway was estimated using the vault distance, the energy to break the guardrail posts, and witness accounts. Based on the bustrajectory over the golf cart pathway and the marks on the opposite side embankment, thebus's speed before takeoff was calculated at 58 mph. Before the vault, the bus impacted 40 Developed by the Engineering Dynamics Corporation.
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Figure 7. Seat layout.
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and fractured 11 guardrail posts. Based on the energy dissipated by deforming theguardrail, fracturing the posts,41 and deforming the front of the bus, the bus speed beforehitting the guardrail was calculated at between 58.6 and 61.9 mph. This range correspondswith statements made by the witness following the bus, that it was traveling approximately60 mph before drifting off the roadway.
The simulation study indicated that the bus underwent an 18-mph change in velocity during the initial 100 milliseconds of the impact with the opposite sideembankment. Figure 8 illustrates a time history of the bus's first and second impacts withthe embankment and its slide to a final rest position. The simulation showed that uponinitial impact of the bus with the embankment, simulated passengers located in the frontand rear of the bus were propelled forward with roughly the same amount of force(longitudinal acceleration). However, the vertical accelerations experienced by passengersin the front and rear were different. (See figure 9.) Upon initial impact, passengers at thefront of the bus were forced downward into the seat cushion, while those at the back of thebus were lifted from the seat. The passengers placed in the center of the bus were not asaffected by the vertical accelerations. These acceleration differences help to explain thegreater severity of the injuries and the displacement of the occupants in the front of thebus.
During the second impact, when the back of the bus hit the embankment, longitudinal accelerations were low, but vertical accelerations again increased in theopposite direction for front and rear passengers. Here, simulated occupants at the back ofthe bus were forced downward while those at the front of the bus were elevated above theseats. The upward acceleration of the simulated occupants at the front of the bus, relativeto the bus reference frame, appeared to be critical in facilitating ejection out of the front ofthe bus as the bus continued to decelerate during the slide to final rest.
41 This simulation assumed undecayed wooden posts.





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Time = 0.7 seconds Time = 1.1 seconds Time = 1.9 seconds Figure 8. Simulation of primary and secondary bus impacts with the embankment.
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Vertical Acceleration (G) Highway Accident Report
According to medical records obtained by Safety Board investigators, the New Orleans driver had a severe cardiac condition and end-stage renal failure. In addition, hehad been released from two jobs and was rejected by another potential employer forpositive drug tests. Because of the circumstances leading to this accident, the Safety Boardfocused its investigation and part of a subsequent public hearing on two specific areas: themedical certification of commercial drivers and drug testing procedures used forcommercial vehicle operations. This section describes the current medical certificationprocess for interstate commercial drivers, including pertinent Federal regulations, anddiscusses actions taken by the Safety Board, FHWA, and the FMCSA to improve theprocess. Following that discussion is a description of drug testing procedures and ofSafety Board and Federal actions to improve drug testing.
Medical certification, which qualifies an individual as being fit to drive a commercial vehicle, became a Federal requirement under the Motor Carrier Act of 1935.
The first physical qualification standards were established in 1939 and required thatdrivers be in good physical and mental health and have good eyesight, adequate hearing,and no addiction to narcotic drugs or alcohol. These qualifications have been modified andexpanded three times since then, with the most recent major modification occurring in1970.42 The Driver and Carrier Operations Division of the FMCSA has medical oversight over approximately 400,000 interstate carriers and 9 million commercial drivers. It doesnot have regulatory authority over the health care professionals who conduct thecommercial driver examinations. In 1999, the division had a fiscal year budget of slightlyover 1 million dollars.43 The division employs three registered nurses (two full-time andone part-time) and a transportation specialist at FMCSA headquarters. Three full-timehealth and welfare specialists are being hired to assist with the vision exemption programand in the development of driver qualification regulations. In addition, each of four fieldservice centers has a medical programs specialist who conducts skill performanceevaluations for limb-impaired drivers.44 42 FMCSA, Physical Qualification of Drivers; Medical Examination; Certificate (final rule), 65 Federal Register (FR) 59363, October 5, 2000.
43 Sandra Zyworkarte, R.N., M.P.H., FMCSA, testimony, National Transportation Safety Board public hearing, Effectiveness of Commercial Driver Oversight Programs, New Orleans, Louisiana, January 20 through 21, 2000.
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Medical certification is a requirement for all U.S. interstate commercial vehicle drivers who drive a vehicle that: Has a gross vehicle weight rating or gross combination weight rating, or grossvehicle weight, or a gross combination weight of 10,001 pounds or more,whichever is greater; or Is designed or used to transport more than 8 passengers (including the driver)for compensation; 45 or Is designed or used to transport more than 15 passengers, including the driver,and is not used to transport passengers for compensation; or Is used to transport material found by the Secretary of Transportation to behazardous under 49 United States Code (U.S.C.) 5103 and transported in aquantity requiring placarding as prescribed by the Secretary under 49 CFR,subtitle B, chapter I, subchapter C.46 Intrastate drivers are subject to the physical qualification regulations of their home States. All of the States have adopted regulations based on the Federal requirements,although many grant exemptions for certain medical circumstances. Procedures notspecifically covered in the Federal regulations vary from State to State (appendix D).47 Interstate commercial drivers are required to certify that they meet the medical requirements in 49 CFR 391.41. To drive a commercial vehicle, drivers must also obtain aCDL. The Federal regulations governing the CDL generally apply to both intrastate andinterstate commercial drivers (49 CFR 383).48 The Federal regulations pertaining to the physical fitness qualifications required for a medical certificate are contained in 49 CFR 391.41, which states: A person shall not drive a commercial motor vehicle unless he/she is physicallyqualified to do so and, except as provided in 391.67, [49] has on his/her person theoriginal, or a photographic copy, of a medical examiner's certificate that he/she isphysically qualified to drive a commercial motor vehicle.
44 According to Walter McVay, medical programs specialist for the FMCSA Eastern Service Center, medical programs specialists must attend a 3- to 5-day training program on the qualification standards forlimb-impaired drivers. In addition, they are given guidelines to assist them in evaluating the performance of drivers with specific types of impairments.
45 Title 49 CFR 390.3 exempts drivers of vehicles that transport less than 16 passengers (including the driver) from obtaining medical certification.
46 Title 49 CFR 390.5.
47 Association for the Advancement of Automotive Medicine and Federal Highway Administration, Update of Medical Review Practices and Procedures in U.S. and Canadian Commercial Driver Licensing Programs, PB97-194393INZ (Springfield, Virginia: National Technical Information Service [NTIS], 1997).
48 In general, a CDL is required when driving a vehicle that is: (1) over 26,000 pounds, (2) designed to transport 16 or more occupants, including the driver, or (3) used to transport hazardous materials.
49 Title 49 CFR 391.67 exempts farm vehicle drivers of articulated commercial motor vehicles.
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All interstate commercial vehicle drivers must be examined at least every 2 years in accordance with 49 CFR 391.43, and certified by an examiner to operate a commercialvehicle. Before 1992, only medical doctors and doctors of osteopathy were allowed toperform examinations.50 In 1992, the regulations were modified to allow certain Statelicensed, certified, and/or registered health care professionals to perform examinations,including medical doctors, osteopaths, physician assistants, advanced practice nurses, andchiropractors.51 The laws of each State determine which of these types of health careprofessionals may perform commercial driver examinations. The FHWA hoped that byexpanding the pool of examiners, it would lower the cost of the examination and givedrivers greater flexibility in arranging for the exam.52 Federal regulations state thatexaminers must know the specific physical and mental demands associated with operatinga commercial vehicle and be proficient in the medical protocols necessary to adequatelyperform an examination.53 There are no Federal training and certification programs toensure that examiners are familiar with the regulations. In addition, no registry exists forcommercial vehicle driver examiners.
Instructions for performing and recording physical examinations accompany the regulations. (See appendix E for 49 CFR 391.43(f) instructions and appendix F for 49CFR 391.41 medical advisory criteria.)54 The FMCSA distributes free medical advisorycriteria upon request, and since 1997, has maintained a Web site containing medicaladvisory criteria. In addition, the FMCSA posts medical waiver and seminar reports on itsWeb site, with topics ranging from vision exemptions to cardiac disease.
The content and general format of the examination form used by the New Orleans examiner is specified in 49 CFR 391.43(f). An official form does not exist, but States,carriers, and other parties may produce their own version of the form as long as it containsthe information specified in the Federal regulations. This information has threecomponents: (1) health history (which is completed by the applicant), (2) the physicalevaluation section, and (3) the medical certificate, which must be completed if the driverpasses the physical. There are no instructions for an examiner who finds a driverunqualified to operate a commercial vehicle.
50 Qualification of Drivers: Medical Examination, 57 FR 33276, July 28, 1992.
51 Title 49 CFR 390.5.
52 N. Hartenbaum, The DOT Medical Examination: A Guide to Commercial Drivers' Medical Certification (Beverly Farms, Massachusetts: OEM Press, 1997).
53 Title 49 CFR 391.43(c)(1).
54 Text portion of advisory reproduced on March 26, 2001, from the Web site of the FMCSA Highway Accident Report
The medical examination instructions that regularly55 accompany the medical examination form include 13 basic requirements covering physical conditions such as lossof limbs, impairment of limbs, cardiovascular impairments (for example, myocardialinfarction, angina pectoris, coronary insufficiency, thrombosis, high blood pressure),muscular impairment (including epilepsy), diabetes, eyesight and hearing problems, anduse of controlled substance. A medical certificate is not to be granted to those withepilepsy, insulin-treated diabetes, poor hearing, or poor vision, as defined in theregulations. Other physical conditions may prevent an individual from obtaining a medicalcertificate, and Federal regulations make it the medical examiner's responsibility to ensurethat only qualified drivers obtain the certificate.
In October 2000, the FMCSA published the final rule for a new 8-page examination form. The final rule provided for the changes to the content and format of theexamination form without substantially changing the Federal regulations.56 The new formwill be discussed in detail in later sections.
Medical Examination Process
If an examiner believes that an applicant is physically qualified to drive a commercial motor vehicle in accordance with 49 CFR 391.41, the examiner signs andcompletes the medical certificate and furnishes a copy to the applicant and employer. Themedical certificate indicates that the completed examination form will be kept on file inthe examiner's office. The examiner may certify an applicant for less than 2 years if theapplicant's condition warrants further scrutiny. The examiner or driver is not required toinform the motor carrier, local or Federal governments, or any other party if the driverfails the physical examination. Although no requirement exists for the examination formto be reviewed or tracked by a State or Federal authority, a number of States do so,including Louisiana (see appendix D).
Alternative Qualifications, Exemptions, and Waivers
An individual who has a loss or impairment of a limb that would not otherwise prevent him or her from operating a commercial vehicle may still qualify to do so underthe Alternative Physical Qualification Standard for the Loss or Impairment of Limbs.57The individual must apply for a Skill Performance Evaluation (SPE) certificate from aState Director of the FMCSA. The SPE (formerly the Limb Waiver Program) wasdesigned to allow persons with the loss of a hand, foot, or limb to meet fitnessqualifications through the use of prosthetic devices or equipment modifications. Sincethere are no medical aids equivalent to the original body limb, certain risks are stillpresent, and thus restrictions may be included on individual SPE certificates when a StateDirector of the FMSCA determines they are necessary to be consistent with safety and 55 Title 49 CFR 391.43(f) states that "The medical examination shall be performed, and its results shall be recorded, substantially in accordance with the following instructions and examination form…." However, it does not require that the instructions provided accompany the examination form itself.
56 65 FR 59363, October 5, 2000.
57 Title 49 CFR 391.49.
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public interest. If the driver is found otherwise medically qualified, the examiningphysician must include the statement "medically unqualified unless accompanied by aSPE certificate" on the driver's medical certificate.58 Under 49 CFR 381.300, a carrier or a driver may apply for an exemption from certain FMCSRs. An exemption is defined as temporary regulatory relief from one ormore FMCSRs given to a person or class of persons subject to the regulations or personswho intend to engage in an activity that would make them subject to the regulations. Anexemption from the commercial driver fitness regulations provides the person or class ofpersons with relief from the regulations for up to 2 years and may be renewed. TheFMCSA is only considering exemptions from the visual requirements at this time.
A waiver is temporary relief from one or more FMCSRs given to a person subject to the regulations or given to a person who intends to engage in an activity subject to theregulations.59 A waiver provides the person with relief from the regulations for up to 3months. It is intended for unique, nonemergency events and is not a source of relief fromdriver physical qualification requirements.60 Resolving Medical Evaluation Conflicts
Motor carriers often contract with an examiner to conduct commercial driver physical examinations. When a carrier's examiner and a driver's physician disagreeregarding the driver's fitness to operate a commercial vehicle, 49 CFR 391.47 provides amethod for resolving the conflict.
The driver and the carrier must obtain the opinion of an impartial medical specialist in the field in which the medical conflict arose. The specialist's opinion issubmitted to the FMCSA Office of Motor Carrier Research and Standards (OMCRS),along with medical records supporting the specialist's opinion, medical records andstatements of the carrier's and driver's examiners, proof of the disagreement between thecarrier and the driver, and other supporting documentation. The OMCRS director willdetermine the driver's fitness. The driver is considered disqualified until the time adecision is made, or until the director orders otherwise.
As part of the Motor Carrier Safety Assistance Program (MCSAP),61 safety inspectors may check whether a driver possesses a current medical certificate, whether the 58 Text portion of advisory reproduced on March 26, 2001, from the Web site of the FMCSA 59 Title 49 CFR 381.200.
60 Sandra Zywokarte, FMCSA, telephone interview, May 2001.
61 The MCSAP is a Federal grant program that provides financial assistance to States to reduce the number and severity of accidents and hazardous materials incidents involving commercial motor vehicles(CMV). The goal of the MCSAP is to reduce CMV-involved accidents, fatalities, and injuries through consistent, uniform, and effective CMV safety programs. States accomplish aspects of this goal through inspections of carrier terminals and of commercial vehicles.
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driver has an SPE certificate or the proper exemption, and whether the carrier has includeda current copy of a driver's medical certificate in the driver's file. Among other violations,drivers can be cited during the inspection for any of these five regulatory violationsinvolving medical examination certificate or form. These are listed below: 391.41(a) - no medical certificate in driver's possession, 391.43(e) – missing exemption on a medical certificate, 391.43(g) - improper medical examiner's certificate, 391.45(b) - expired medical examiner's certificate, and 391.49(j) - no valid SPE certificate in the driver's possession.
According to the Commercial Vehicle Safety Alliance (CVSA) North American Standard Out-of-Service Criteria,62 a driver can be placed out of service if she or he doesnot have the proper SPE certificate or exemption or is not wearing corrective lenses or ahearing aid as required by his or her medical certificate. The States have also enacted lawsthat give them the power to disqualify drivers who do not meet the level of fitnessdescribed in the State or Federal regulations (appendix G).63 The Federal regulations contained in 49 CFR 390.35 prohibit making fraudulent or intentionally false statements on any application, certificate, report, or record required bythe FMCSRs, to include the commercial driver medical examination form. The penalty forfalsifying the medical examination form consists of civil fines.64 The FMCSA hasperformed 169 enforcement actions in the past 10 years on drivers and carriers who havefalsified medical records, with fines totaling $92,761. Of those enforcement actions, 142were conducted by the FMCSA against drivers and 27 against carriers. The FMCSA doesnot compile data on whether any of the enforcement actions against drivers also led todisqualifications.65 Louisiana State Medical Qualification Regulations
Intrastate drivers in Louisiana are subject to the same fitness regulations as interstate drivers. In addition, since 1996, Louisiana has required individuals who wererenewing or obtaining their commercial driver's license to submit their most recentlycompleted medical examination form to the State licensing agency. A trained staff66reviews every examination form submitted for omissions, inconsistencies, and violationsof the Federal fitness regulations. Approved forms are scanned into a computerizedimaging system and filed as part of the driver's records, where they can be accessed andreviewed by the licensing agency staff as needed. If the licensing agency needs 62 North American Standard Out-of-Service Criteria, 2001.
63 Update of Medical Review Practices and Procedures in U.S. and Canadian Commercial Driver 64 Title 49 CFR 386, subpart B.
65 Sue Halladay, Transportation Specialist, FMCSA, April 2001.
66 According to the Louisiana CDL help desk supervisor, staff complete an informal 3- to 5-day course on the CDL and commercial driver medical certification process and are mentored for up to a year.
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clarification regarding an examination form, the licensing agency contacts the examinerwho conducted the examination.
The State has had a medical advisory board since 1968, consisting of 18 members from fields such as cardiology, internal medicine, neurology, ophthalmology, andpsychiatry. The medical advisory board convenes every 3 months. It advises the licensingagency on medical and visual standards and also reviews individual cases, such asconflicts between the licensing administration and a driver regarding the driver's physicalfitness.
Louisiana does not require commercial driver examiners to report drivers that they believe unfit. Although anyone may voluntarily report an unfit driver to the LouisianaDivision of Motor Vehicles, reports of unfit drivers are not always confidential.67 Onlyhealth care providers that report unfit drivers have immunity from legal action, as stated inArticle 40, Section 1356, of the Louisiana Revised Statutes: No person shall have a cause of action for damages or loss against any health careprovider nor shall any criminal liability be imposed as a result of a report by thehealth care provider to the Department of Public Safety and Corrections or theLouisiana Medical Advisory Board of any visual ability or physical condition,impairment, or disability of an applicant for a driver's license or of a licenseddriver, which may impair such person's general ability to exercise ordinary andreasonable control in the operation of a motor vehicle, whether the health careprovider is statutorily mandated to make such a report or whether such report ismade voluntarily, when the health care provider is acting without malice and inthe reasonable belief that such action is warranted to protect the public.
At least 19 States do not offer immunity to physicians or to other health care providers. At least 37 do not offer immunity to persons other than health care providerswho report an unfit driver in good faith (see appendix G).68 If a health care provider in Louisiana sends written notification to the licensing agency that a driver presents an "immediate risk" or "should not be driving," the driver'slicense is immediately suspended and a pickup order issued for a law enforcement officerto seize the license. If the examiner expresses concern over a particular condition but doesnot specify that the driver may be a "danger" or a "risk," the licensing agency sends thedriver notification that he or she needs to provide a medical report on that condition. Thedriver's license is put on a pending status, and the driver is given 30 days to respond. If thedriver does not respond within the given timeframe, his or her license is suspended and apickup order is issued.69 67 Update of Medical Review Practices and Procedures in U.S. and Canadian Commercial Driver 68 Data are not available for all States.
69 Carla Doris, Louisiana Department of Motor Vehicle CDL help desk supervisor, telephone interview, December 2000.
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Medical Certification Program for Airmen
In January 2000, the Safety Board conducted a 2-day hearing in New Orleans that examined the adequacy of commercial driver oversight, including the medicalcertification process.70 During the hearing, testimony was given regarding the FAA'smedical certification process for airmen71 and how it compares with that for commercialvehicle drivers.
With an annual budget of $5.7 million in 1999, the FAA's Division of Aeromedical Certification is responsible for certifying the health of approximately 600,000 airmen.
Medical certification is required for any airman acting as pilot-in-command or otherrequired crewmembers of an aircraft (except for free balloons, gliders, and ultralights).
This includes student pilots in solo flight as well as private, commercial, and airlinepilots.72 These airmen are required to go to one of approximately 5,500 FAA-trained and-registered aviation medical examiners (AMEs) for their certification. All AMEs are eitherdoctors of medicine or osteopathy. To become an AME, an individual must attend a1-week seminar on the FAA's medical certification program and then take a refreshercourse every 3 years.73 Each AME receives a copy of the Aviation Medical Examiner'sGuide, which contains step-by-step instructions performing the physical examination, aswell as specific guidance for handling the most commonly encountered abnormalfindings.
Each AME is assigned examination forms that can be used only by that individual.
A unique serial number is printed on each form so that the form can be tracked by theDivision of Aeromedical Certification. The AME must then send the completedexamination form to the division, regardless of whether the airman passes the physical. Asof October 2000, the process became fully computerized; now most examination formsare completed and transmitted to the division via the Internet. Data from nonelectronicforms are also entered into the system when received by the division. A computer systemperforms a preliminary review of all forms; forms that are considered nonstandard74 (forinstance, when the airman was denied certification or the certification decision wasdeferred) are reviewed by hand. The division employs 33 reviewers especially trained forthis purpose.75 The division's database of examination information, which was establishedin 1953, gives the FAA the ability to use historical data to identify inconsistencies on an 70 National Transportation Safety Board public hearing, Effectiveness of Commercial Driver Oversight Programs, New Orleans, Louisiana, January 20 through 21, 2000. See <http://www.ntsb.gov/events/2000/comm_driver/agenda.htm> for the public hearing agenda.
71 A pilot, mechanic, or other licensed aviation technician.
72 For frequently asked questions regarding the medical certification of pilots, see the FAA Office of Aviation Medicine, Civil Aeromedical Institute, Web site<http://www.cami.jccbi.gov/AAM-300/amcfaq.html>.
73 Dr. Warren Silberman, Manager, Division of Aeromedical Certification, FAA, testimony, Commercial Driver Oversight Public Hearing, Safety Board.
74 A nonstandard form is one that has incomplete entries, has entries that are inconsistent with the certification decision, or has entries that for any other reason make the form conspicuous.
75 Rita Smith, Division of Aeromedical Certification, FAA, telephone interview, December 2000.
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individual's examination form. In addition to utilizing its tracking capabilities, the FAAcan make simple statistical queries on this data.
The regulations describing the fitness standards that medically certified airmen must meet were last updated in 1996. The regulations cover physical and mentalconditions ranging from vision, hearing, cardiovascular condition, diabetes, and epilepsyto an airman's mental state.76 The regulations give AMEs some discretion in diagnosingand certifying the fitness of these airmen. As noted, AMEs receive training and guidanceto help with their certification decision and may call the division for further guidance.
Additionally, the FAA sends all AMEs the Federal Air Surgeon's Medical Bulletin, aquarterly newsletter that provides current information on the medical certificationprocess.77 The regulations state that it is unlawful to make fraudulent or intentionally false statements on an application for a medical certificate or any other document that is used toverify or validate an airman's fitness.78 Doing so would be a basis for actions such asrevoking the airman's medical certificate, denying all applications for medicalcertification, denying applications for waivers, or revoking an airman's pilot certificate,depending on how severe the FAA considers the offense. In addition, the U.S.C. allows fora $250,000 fine, 5 years of imprisonment, or both.79 An airman may apply for an authorization of special issuance of a medical certificate if he or she has a well-controlled condition or a condition that has been inremission. A special issuance authorization may be granted for such conditions asinsulin-controlled diabetes, hypertension, and coronary artery disease, depending on thetype of flying an airman does.80 An AME may authorize a special medical flight test,practical test, or medical evaluation to determine whether to grant special issuance.
Airmen who are granted special issuance authorizations are usually required to haveexaminations more frequently than healthy pilots.81 An airman may also be granted, at the discretion of the Federal Air Surgeon, a Statement of Demonstrated Ability (SODA), instead of a special issuance authorization.
This is given to a person whose disqualifying condition is static or nonprogressive andwho has been found capable of performing airman duties without endangering publicsafety. A SODA does not expire and authorizes a designated aviation medical examiner toissue a medical certificate of a specified class if the examiner finds that the airman'scondition has not adversely changed.82 76 Title 14 CFR 67 contains the medical fitness standards that apply to airmen.
77 Current and past editions of the Federal Air Surgeon's Medical Bulletin are archived at the FAA Office of Aviation Medicine, Civil Aeromedical Institute, Web site 78 Title 14 CFR 67.403.
79 Title 18 U.S.C. 1001 and 3671.
80 Information obtained on May 30, 2001, from the FAA Office of Aviation Medicine, Civil Aeromedical Institute, Web site <http://www.cami.jccbi.gov/AAM-300/medcon.html>.
81 Title 14 CFR 67.401.
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Individuals may contact the FAA if they believe that an airman is not medically fit to operate an aircraft due to a specific condition. The FAA allows these contacts to beanonymous. An airman suspected of being medically unfit is asked by the FAA to submitrelevant medical records. If an airman is unable to show that he or she is fit to fly, the FAAmay revoke the medical certificate.83 Previous Safety Board Actions
As part of its investigative process, the Safety Board verifies driver qualification information. Several of the accidents the Safety Board has investigated have involveddriver fitness issues (appendix H). This section highlights the Safety Board'srecommendations in this area.
Willow Creek, California. In 1983, an empty dump truck collided head on with
a southbound school bus loaded with 37 passengers. The truckdriver and one school buspassenger were killed, and 31 others were injured. Available medical records indicatedthat the truckdriver had several medical problems, none of which were noted on his latestcommercial medical examination form.84 The events leading to this accident prompted the Safety Board to make the following recommendation to the FHWA: Revise Federal Motor Carrier Safety Regulation 49 Code of Federal Regulations391.43 to incorporate a provision, similar to that specified in 14 Code of FederalRegulations 67.20(A) for Airmen Medical Certification, which will prohibit thefalsification or omission of medical information in connection with a medicalcertification physical examination.
The FHWA responded to this recommendation in May 1988 by adding 49 CFR 390.35 to the FMCSRs. This part made fraudulent or intentionally false statements on anyapplication, certificate, report, or record required by the FMCSRs an offense subject tocriminal or civil penalties. Consequently, in September 1988, the Safety Board classifiedthis recommendation "Closed—Acceptable Action." Middletown, New Jersey. On September 6, 1987, an intercity bus ran off the
road, struck a guardrail and bridge rail, and overturned onto its right side. The busdriverand one passenger sustained fatal injuries, and 32 passengers sustained minor to moderateinjuries. Safety Board investigators found several pieces of evidence indicating that thedriver routinely forged his medical certificates, including his most recent one.85 82 Title 14 CFR 67.401.
83 Jackie Bivins, FAA Division of Aeromedical Certification, telephone interview, May 2001.
84 National Transportation Safety Board, Collision of Humboldt County Dump Truck and Klamath-Trinity Unified District Schoolbus, State Route 96, Near Willow Creek, California, February 24, 1983, Highway Accident Report NTSB/HAR-83/05 (Washington, DC: NTSB, 1983).
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As a result of the information obtained from this accident, the Safety Board made the following recommendation to the FHWA: Revise Title 49 Code of Federal Regulations Part 391 (Federal Motor CarrierSafety Regulations) to require a motor carrier to verify the authenticity of amedical examiner's certificate if the certificate has been prepared by a physicianwho has not been selected by the motor carrier to perform the examination.
Information concerning the fact that verification was made should be retained aspart of the driver's qualification file.
In July 1998, the Safety Board classified this recommendation "Closed— Unacceptable Action," because of the FHWA's failure to revise the relevant regulations.
On October 1998, the FHWA stated that it had completed regulatory negotiation withrepresentatives of the States, the motor carrier industry, and the medical community toinclude the certification of physical fitness of drivers to operate commercial motorvehicles as part of the CDL process. The FHWA stated that it expected to publish a noticeof proposed rulemaking (NPRM) that would satisfy H-88-24 by early 1999. In March2001, an FMCSA representative stated that the release of this NPRM would probably notoccur until 2002, due to a shift in priorities.
Nashville, Tennessee. On November 19, 1988, a Greyhound bus carrying 45
passengers went out of control, rotated 190 degrees clockwise, and overturned. Theunrestrained bus driver and 38 passengers were injured in the accident. Safety Boardinvestigators found that the bus driver had not informed his examiner about hishypertension or about the medications he was taking.86 As a result of this accident, theSafety Board made the following recommendation to the FHWA: Revise section 391.43 of the Federal Motor Carrier Safety Regulations toincorporate a provision that will prohibit the omission of medical information inconnection with a medical certification physical examination; require that whencommercial drivers are examined, they sign a statement certifying that themedical history they have provided is both complete and accurate and that themotor carrier has the authority to obtain information on the bus driver's medicalhistory from their personal health care providers; and require that the medicalhistory form elicit more complete information on drivers, using commonlyunderstandable terminology.
In September 1992, the FHWA stated that it intended to publish a notice in the Federal Register regarding driver physical/medical requirements addressing, but not 85 National Transportation Safety Board, Academy Lines, Inc., Intercity Bus Run-off-Roadway and Overturn, Middletown, New Jersey, September 6, 1987, Highway Accident Report NTSB/HAR-88/03(Washington, DC: NTSB, 1988).
86 National Transportation Safety Board, Greyhound Lines, Inc., Intercity Bus Loss of Control and Overturn Interstate Highway 65, Nashville, Tennessee, November 19, 1988, Highway Accident Report NTSB/HAR-89/03 (Washington, DC: NTSB, 1989).
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limited to, the Safety Board's recommendation. The FHWA further stated that it wasinterested in simplification and improvement of the effectiveness of the examination formand whether the form should be reviewed and retained by the employer. Based upon theFHWA's failure to revise the regulation in the almost 10 years since the recommendationhad been issued, in July 1998, the Safety Board classified this recommendation "Closed—Unacceptable Action." The new medical examination form, created in October 2000, requires that drivers sign a statement certifying that the medical history they have provided is both completeand true and that false or missing information may invalidate the examination and themedical examiners certificate. It also expands the health history section and uses moreunderstandable terminology in the medical history section. It does not give the carrierspermission to obtain driver medical history information from personal health careproviders without the driver's permission.
1990 Safety Study. In 1990, the Safety Board published a study that
investigated the role of fatigue, alcohol, other drugs, and medical factors in 182fatal-to-the-driver heavy truck crashes.87 The Safety Board found that the driver's medicalcondition caused or contributed to 10 percent of the accidents. Over 90 percent ofmedical-condition-related accidents involved some form of cardiac incident.
Because of these findings, the Safety Board recommended that the FHWA: Amend 49 Code of Federal Regulations 391.43 to require more extensive andfrequent state-of-the-art cardiac screening tests and examinations of oldercommercial truck drivers (age 40 and above) and for all commercial drivers withcardiac conditions. Commercial drivers with a cardiac history or condition shouldbe disqualified until cleared by a competent medical authority.
Develop a clear set of medical standards for cardiac risk assessment and requirephysicians to use them in qualifying older commercial truck drivers and forcommercial drivers with cardiac conditions. Medical certification should includemedical state-of-the-art cardiac risk factors.
Improve the medical examination form in 49 Code of Federal Regulations 391.43to ensure that the examining physician is aware of truck operation risk factors andof the physical and other stress producing requirements of commercial truckoperation. Provide for a means for physicians to acknowledge that theyunderstand the rigors of commercial truck operation and that the driver beingexamined is qualified for such commercial truck operations. The physician should 87 National Transportation Safety Board, Vol. 1 of Fatigue, Alcohol, Other Drugs, and Medical Factors in Fatal-to-the-Driver Heavy Truck Crashes, Safety Study NTSB/SS-90/01 (Washington, DC: NTSB, 1990), 2 Vols.
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also certify that he understands the penalties for deliberate and/or false statementson the medical certificate and for medical certificate falsification.
As noted, in October 2000, the FMCSA published its final rule on the new medical examination form. The new form has an expanded health history section and includesquestions on heart surgery and high blood pressure. In addition, the physical evaluationsection, which contains the list of health items the examiner must check, now includesguidelines for blood pressure evaluation, including information on recommendedcertifications periods for drivers with various severities of hypertension. Although theSafety Board noted in its June 20, 2001, response letter that it is unclear how the FMCSAwould enforce the use of the form, since no one other than the examiner must see it, theSafety Board believed that the new form provided a substantially improved resource forexaminers to more appropriately evaluate a driver's cardiac condition. Therefore, theSafety Board classified H-90-24 and -25 as "Closed—Acceptable Alternate Action" inJune 2001.
The new medical examination form also includes a section describing the responsibilities, work schedules, physical demands, and emotional demands thatcommercial drivers may encounter. It also makes medical guidance material moreaccessible. Based on this information, Safety Recommendation H-90-27 was classified"Closed—Acceptable Action" in June 2001.
Central Bridge, New York. The accident that occurred in Central Bridge is
discussed here at length because of the similarities in medical certification issues foundduring that investigation to those in the New Orleans accident.88 The Safety Boarddeferred analyses of medical certification issues affecting the Central Bridge accidentdriver until this report.89 About 10:30 a.m. on October 21, 1999, in Schoharie County, New York, a Kinnicutt Bus Company school bus was transporting 44 students, 5 to 9 years old, and 8adults on an Albany City School No. 18 field trip. The bus was traveling north on StateRoute 30A as it approached the intersection with State Route 7, which is about 1.5 mileseast of Central Bridge. Concurrently, an MVF Construction Company dump truck, towinga utility trailer, was traveling west on State Route 7. The dump truck was occupied by thedriver and a passenger. As the bus approached the intersection, it failed to stop as requiredand was struck by the dump truck. Seven bus passengers sustained serious injuries; 28 buspassengers and the truckdriver received minor injuries. Thirteen bus passengers, thebusdriver, and the truck passenger were uninjured.
The subsequent Safety Board investigation found that the 79-year-old busdriver had a history of serious heart and kidney problems. According to his medical records, the 88 National Transportation Safety Board, School Bus and Dump Truck Collision, Central Bridge, New York, October 21, 1999, NTSB/HAR-00/02 (Washington, DC: NTSB, 2000).
89 School bus operations are exempt from the Federal medical certification regulations. However, this accident has relevancy because many States, such as New York, have adopted the Federal medical certification regulations for its school bus drivers and intrastate commercial carriers. (See appendix C.) Highway Accident Report
driver had a heart attack in 1993, experiencing congestive heart failure and dyspnea(difficulty breathing). He was found to have a severe blockage in the artery supplyingblood to the right side of his heart. He underwent angioplasty, which was successful inopening the artery, but he developed a blood clot in his leg. He was placed on a bloodthinner (Coumadin) as a result of the clot. He was placed on a diuretic as a result of hisheart failure.
Approximately 6 months after his angioplasty, he underwent a stress test to determine whether he had additional coronary artery disease. This test did show reversibleischemia, 90 but the driver's cardiologist decided not to do additional testing or treatment,since the driver was "asymptomatic." A year later, the driver had additional dyspnea dueto "predominantly right-sided heart failure," and his cardiologist increased his diureticdose. The driver continued to use an additional diuretic occasionally (as often as everyother day) to control fluid retention. He had at least one episode of an abnormal heartrhythm.
The driver's diabetes was essentially uncontrolled. He did not follow appropriate dietary restrictions, did not routinely check his blood sugar, and on two occasions was"totally confused"91 about how much medication he was supposed to be taking. His fastingblood sugar levels were routinely over 200 mg/dL, and within a year before the accident,had a blood sugar level of 460 mg/dL.92 His personal physician frequently noted that thedriver was not motivated to control his diabetes, especially when it came to watching hisdiet. The physician had twice considered placing the driver on insulin, once in September1996 and again in January 1999, but had not done so.
According to his medical records, during one visit on October 1995, the driver told his personal physician that it was his practice to take his diabetes medication at 6:30 a.m.,drive the school bus, then have breakfast at 10:30 a.m. The physician told him that thispractice was unacceptable and that the driver ran the risk of having a low blood sugarreaction while driving the bus.93 The physician noted that the driver said he understood thedangers and would change his behavior. The driver's medical records do not note anythingfurther with regard to the driver's diet and medication as it related to his driving schedule.
On September 4, 1999, the driver visited a physician for his medical certification examination. The treating physician was not the driver's regular physician, and she onlyhad access to the medical history the driver provided. On the health history section of theexamination form, the driver did not note treatment for congestive heart failure and did notlist any of his cardiac medications or his blood thinner. The physician performing the CDLexamination was aware that the driver was a diabetic, but did not direct the driver to obtain 90 Decreased blood flow to a portion of the heart as a result of exercise, a condition that improves with 91 Physician's notes from September 1997. See docket number HWY-00-FH-001.
92 The normal range for fasting blood sugar levels is approximately 75 to 115 mg/dL.
93 The American Diabetes Association <www.diabetes.org> list includes the following symptoms for hypoglycemia (low blood sugar): shakiness, dizziness, sweating, hunger, headaches, sudden moodiness or behavior changes, clumsy or jerky movements, difficulty paying attention, and confusion.
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a 6-month evaluation as required by the New York State Commissioner Regulations, Part6, and the New York Department of Motor Vehicles (NYDMV), Article 19-A. Thoserequirements consist of "certification by the employee's personal physician that his or hercondition has remained stabilized and that he or she has not had an incident ofhypoglycemic shock since the last certification." No medical review of the driver'sphysical examination form was apparently performed by anyone, other than the examiningphysician. Kinnicutt also was aware of the driver's diabetic condition and requested astatement from his personal physician, to comply with the NYDMV regulations, regardingthe driver's diabetic condition in November 1998. The driver's personal physician notedthat "he has no hypoglycemic attacks" but did not note whether the driver's condition wasstabilized. The Safety Board concluded that the busdriver's performance might have beenaffected by his medical condition, his advanced age, or both.
Recent Federal Initiatives
New Model Medical Examination Form. In October 2000, the FMCSA
published its final ruling on a new model medical examination form and certificate.
According to the FMCSA, the previous examination form had not been revised since 1970and did not always reflect current knowledge and practice. The new form includes moreupdated and simplified information. The FMCSA expects the new form to reduce theincidence of errors and provide more uniform medical examinations to commercial motorvehicle drivers. Examiners may use the previous form until November 2001, but must usethe new form after that date.
The new form was developed under a contract with the Association for the Advancement of Automotive Medicine (AAAM), and was reviewed by a group ofmedical providers, State agency representatives, motor carriers, FHWA field staff, andother interested groups. Although the final ruling updated the examination form in contentand format, it did not modify or update any of the underlying physical qualificationstandards contained in the regulations.
The new form is organized into three sections.94 The first section inquires about the driver's health history. This section has been modified and expanded over the previousform by replacing some medical terminology with a list of symptoms, expanding inquiriesinto cardiovascular diseases, and expanding inquiries to include sleep disorders andmedication (prescription and over-the-counter). If a driver responds that he or she has aparticular symptom or disease, the driver must expand on his or her answer. At the bottomof this section, the driver is required to certify that the information provided is completeand accurate and acknowledge that inaccurate, false, or missing information mayinvalidate both the examination and the medical certificate.
The second section covers the physical examination and tests performed by the examiner. Several changes have been made to this section, mainly to reduce the potentialfor errors by an examiner. Not only does the form include the relevant Federal physical 94 As with the current form, the content of the new form is defined, but the States may determine its Highway Accident Report
qualification standards, but it also has guidance on selected testing and evaluationprocedures, such as evaluating a driver's blood pressure and urine sample. The secondsection also includes an area to be completed if the driver does not qualify for a 2-yearcertificate but qualifies for a certificate of less than 2 years.
The final section of the examination form details the Federal physical qualification standards found in 49 CFR 391.41, describes the driver's role and the type of duties facedas a result of that employment, and contains the FMCSA's advisory guidelines to helpexaminers better assess a driver's physical qualifications. In addition, the form includesthe telephone number for the FMCSA Office of Bus and Truck Standards and Operations;a representative of the FMCSA Driver and Carrier Operations Division stated that she hasnoticed an increase in the number of incoming telephone calls since publishing the newexamination form. The Driver and Carrier Operations Division currently fieldsapproximately 30 calls a day.95 Merger of the CDL and Medical Certification Processes. The
Commercial Motor Vehicle Safety Act of 1986 created the CDL and gave the DOT theauthority to link the CDL with the medical certificate. In 1990, FHWA began exploringthe possibility of merging the CDL and medical certification processes and assigningstewardship of the program to the States. The FHWA saw several benefits to this.96 First,the merger would minimize the documents that a commercial vehicle driver would need tocarry. Second, since the presence of a valid license would also indicate physical fitness, itwould reduce the number of separate documents that law enforcement would have toauthenticate. Third, transferring the medical certification process to the States could takeadvantage of their existing infrastructure to begin recording and tracking medicalcertificates. In addition, State medical advisory boards could process Federal, as well asState, SPE certificates and exemptions and attend to other fitness-related issues.
In an effort to determine whether States would be able to manage medical certification along with the CDL process, six States (Alabama, Arizona, Indiana,Missouri, North Carolina, and Utah) were selected to participate in a pilot project thatrequired each to create a prototype medical review program.97 As part of the program, thelicensing agency of each State was required to collect the completed medical examinationforms for review as part of the process for obtaining a license to operate a commercialmotor vehicle. The results of this study prompted the FHWA to conclude that the pilotStates "demonstrated the potential capability of assuming the responsibility of thecommercial driver fitness certification." The agencies were able to detect unfit drivers andcould restrict them from driving within the parameters set by the licensing agency and theState medical advisory board.
95 Sandra Zywokarte, FMCSA, telephone interview, May 2001.
96 FHWA, "Commercial Driver Physical Qualifications as Part of the Commercial Driver's License Process," advance notice of proposed rulemaking (ANPRM); request for comments (July 15, 1994) andnotice of intent to form a negotiated rulemaking committee (April 29, 1996), FHWA docket number 97 Association for the Advancement of Automotive Medicine, Prototype State Review Program: Final Report, DTFH 61-90-C-00098 (Washington, DC: FHWA, 1995).
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During the pilot study, the FHWA tested the hypotheses that a significant number of commercial vehicle drivers were either forging the medical examiner's signature,altering the long form, driving without a medical certificate, or driving with an expiredcertificate. The data gathered from the six pilot States indicated that these hypotheses werenot always supported. However, several issues were uncovered. In three States, a highproportion of the examination forms had to be returned to the applicants because someentries were either incomplete or inconsistent with other entries.98 Many of the omissionsor inconsistent entries were related to vision testing and blood pressure readings. Onesomewhat common mistake was examiners forgetting to note the expiration date on thecertificate, which can be particularly important for drivers requiring periodic evaluation(such as, diabetes or borderline high blood pressure).
The reviews also yielded a number of applicants who were issued medical certificates, but who did not meet the medical standards. For example, in Missouri, of the8,086 examination forms received and analyzed by the licensing agency, 32 drivers wereidentified who did not meet Federal fitness standards, despite being issued medicalcertificates by certified examiners. In Arizona, of the 39,678 examination forms receivedand reviewed by the motor vehicle department, 2,662 drivers (6.7 percent) were found notto meet the Federal fitness standards. These drivers were subsequently denied medicalcertification and had their CDL driving privileges cancelled. Another 175 drivers had theirdriving privileges cancelled for falsifying their medical long form.
In 1994, the FHWA released an advance NPRM (ANPRM) on the merger of the CDL and the medical certification processes.99 It described several reasons for consideringthe merger (many given above), and listed several issues that would need to be resolvedfor the merger to take place, to include the need for a medical fitness tracking and reviewsystem and the need for an examiner registry.
In 1996, the FHWA released a notice of intent to form a Negotiated Rulemaking Advisory Committee on the merger. The purpose of the advisory committee was topromote an open exchange of ideas between interested parties, with the hope that it wouldlead to innovative resolutions to the issues surrounding the merger. The notice suggestedsix topics of discussion, which were based on prior interviews with potential committeemembers: Whether the physical qualification guidelines currently used by the agencyshould be modified to more effectively implement the current medicalstandards.
The scope of any medical qualifications tracking system which might be usedby law enforcement officials and carriers.
98 Alabama returned 43.3 percent of the long forms because they were incomplete; Arizona, 32.6 percent; and Missouri, 31 percent (noncertified examiners) and 17 percent (certified examiners). Two other States reported low return rates: Indiana, 5 percent, and Utah, 2.9 percent. A return rate was not given for North Carolina.
99 See FHWA docket number MC-93-23.
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Whether useful information could be utilized from the federally funded StatePrototype Medical Review pilot programs in drafting a rule on merging CDLand physical qualification requirements.
The amount of control various parties should have over the medical reviewprocess, and whether the current commonly used procedure, in which acompany directs its drivers to physicians it selects, needed to be replaced orsimply modified.
How best to clarify the current physical examination requirements andguidelines and communicate them effectively to the medical providercommunity.
Whether there was a way to merge the separate medical and CDL requirementswithout burdening the small operator who moves to another State.
During the Safety Board's January 2000 hearing on driver oversight, an FMCSA representative stated that an NPRM on the merger was expected sometime in the year2000.100 However, changed priorities have delayed the projected release date of thisNPRM until 2002.101 California, Arizona, Utah, and Nevada have already formally merged the medical certification and the CDL processes together. In California102 and Arizona,103 commercialdrivers are required to provide their respective licensing agency with a complete andcurrent medical examination form every 2 years. The licensing agency reviews and trackseach form. If a problem is found with the information on a form, the form is sent back tothe driver for clarification. If the driver does not respond within 30 days, the licensingagency can take action.104 Since medical fitness is an integral part of having a CDL,drivers with invalid or missing medical certification risk immediate disqualification and afine. Both States have systems that allow law enforcement to check a driver's licensestatus during routine stops and safety inspections. Because of this, law enforcement is ableto prevent unfit drivers from driving.105 100 Robert Redmond, FMCSA, testimony, Commercial Driver Oversight Public Hearing, Safety Board.
101 Teresa Doggett, FMCSA contact for the NPRM on the CDL-medical certification process merger, telephone conversation, April 2001.
102 Soubeih Al-Jundi, Principal Driver Safety Officer, California Department of Motor Vehicles, telephone interview, April 2001.
103 Lupe Valdivia, Arizona Motor Vehicle Division Medial Review Program, telephone interview, May 104 Arizona immediately suspends the driver's license. California may take any one of a number of actions, including converting the CDL to a private vehicle license.
105 As part of its investigation, the Safety Board also reviewed the medical fitness requirements of Mexico, Canada, the United Kingdom, and Australia, and found that all but Australia have incorporated medical fitness requirements into their commercial driver's license programs. (See appendix I.) Highway Accident Report
Alcohol and Drug Testing Procedures
Postcrash toxicological tests on the busdriver involved in the New Orleans crash detected THC, the major active substance in marijuana, in the driver's blood andtetrahydrocannabinol carboxylic acid (THC-COOH), the major inactive metabolizedderivative of THC, in the driver's blood and urine. This driver had tested positive fordrugs on four previous occasions—twice as an employee of The Regional TransitAuthority, once as an employee of Westside Bus Service, and once when applying for ajob with Greyhound. Below is the applicable background information on the drug testingregulations for commercial vehicle drivers.
Regulations on Commercial Vehicle Driver Drug Testing
According to 49 CFR Part 382, drivers holding a CDL must be tested for five controlled substances106 before holding a safety-sensitive position with a carrier and mayalso be tested at certain times during employment with that carrier. It is the carrier'sresponsibility to comply with the drug testing regulations.
Use of a controlled substance is determined by collecting a urine sample from the driver and having it analyzed by a drug testing laboratory certified by the U.S. Departmentof Health and Human Services. Title 49 CFR 40 details the procedures that must befollowed to collect the sample. Results of the analyses are then relayed by the laboratoryto an MRO107 who reviews the results and the chain of custody before releasing the results.
If a controlled substance is found in concentrations above the reporting levels specified in49 CFR 40.29,108 or if there is evidence that the specimen provided by the employee wassubstituted or adulterated, the MRO contacts the employee to determine whether there arelegitimate reasons for the results and whether the employee would like a retest.109 TheMRO informs the designated employee representative (DER) of all positive and negativetest results.110 Alcohol tests are administered by a breath alcohol technician or a screening test technician111 who is trained in the operation of an evidential breath testing device oralcohol screening device. An employee found to have an alcohol concentration of 0.02 ormore must take a confirmatory test. The results of all alcohol tests are submitted to theDER.
106 Marijuana, cocaine, opiates, phencyclidines (PCPs), and amphetamines.
107 Title 49 CFR 40, Subpart G, describes the qualifications and functions of an MRO.
108 Under the new drug testing rule that takes effect in August 2001, the controlled substance chart in 49 CFR 40.29 will appear under 49 CFR 40.87.
109 When a urine specimen is taken, the specimen is split and sent to two laboratories. One laboratory analyzes the urine, while the second laboratory stores the urine specimen in case the employee requests aretest following an initial positive drug test result.
110 The results may also be reported to a consortium or third party administrator, if so arranged by the 111 Title 49 CFR 40, Subpart J, describes the qualifications of a breath alcohol technician and a screening test technician.
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Consequences of a Positive Drug or Alcohol Test. If an alcohol test reveals an
alcohol concentration exceeding 0.02, the carrier must not allow the driver to performsafety-sensitive functions, including driving a commercial vehicle, for at least 24 hours.
If a driver tests above the reporting level for a controlled substance, or is found to have an alcohol level of more than 0.04, the driver is not allowed to performsafety-sensitive functions, including driving a commercial motor vehicle, until beingevaluated by a substance abuse professional (SAP).112,113 Failure to prevent a driver fromperforming a safety-sensitive function until that time may subject the carrier and the driverto the penalty provisions of 49 U.S.C. section 521(b),114 which includes immediatelyplacing the driver out of service and levying a civil penalty not to exceed $2,500.
The SAP must determine a course of treatment to help the driver resolve problems with abuse. The SAP must also reevaluate the driver to determine whether he or sheproperly followed the prescribed treatment program. Before being able to return to dutyfollowing the evaluation and treatment for drug or alcohol abuse, a driver must pass areturn-to-duty test. In addition, the driver is subject to at least six unannounced drug andalcohol tests during the first 12 months following his or her return to duty, with additionaltesting possible in the following 48 months (a total period of 5 years).115 An employer may also independently establish guidelines for disciplinary action, which may include the termination of employment.116,117 No regulatory requirement existsto report a driver who has tested positive to any regulatory or enforcement authority.
Not all drivers who are required to have a current medical certificate are also required to be drug tested, but the regulations pertaining to the physical qualification ofdrivers do address the use of controlled substances. Title 49 CFR 391.41(12)(i) states thata person is physically qualified to drive a commercial motor vehicle if that person "doesnot use a controlled substance identified in 21 CFR 1308.11 Schedule I,118 anamphetamine, a narcotic, or any other habit-forming drug." Preemployment Drug Tests. The Federal regulations state that an employer must
not allow a new driver to drive or perform other safety-sensitive functions unless he or shehas been tested for controlled substances and been found negative.119 The employer may 112 Referral, evaluation, and treatment regulations are given in 49 CFR 382.605(b).
113 Title 49 CFR 40, Subpart O, describes the qualifications for a substance abuse professional.
114 Title 49 CFR 382.507.
115 Title 49 CFR 382.605(c)(2)(ii).
116 Title 49 CFR 382.601(c).
117 During the Safety Board's Driver Oversight hearing in January 2000, Peter Van Beek, Director of Safety, Coach USA, pointed out that States may restrict the actions of carriers in response to a positive drugtest.
118 Title 21 CFR 1308.11, Schedule I, lists controlled substances under the following families: opiates, opiate derivatives, marijuana derivatives, hallucinogenics, depressants, and stimulants. It does not list cocaine, but 49 CFR 391.41(b)(12)(i) covers this drug under the phrase, "any other habit-forming drug." 119 Title 49 CFR 382.301(a).
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waive the test, if, during the preemployment process, the employer had verifiedknowledge120 that the driver participated in a controlled substance testing program withinthe previous 30 days, and (1) was tested and found negative within the past 6 months or(2) participated in a random controlled substances testing program for the previous 12months with no violations in the past 6 months.
In addition to preemployment testing, the regulations specify that employers must as part of a random drug testing program (49 CFR 382.305), after an accident of specified severity (49 CFR 382.303), when there is reasonable suspicion of drug and alcohol use (49 CFR 382.307), before being allowed to return to work after testing positive for a controlledsubstance or a concentration of alcohol above 0.04 (49 CFR 382.309), and as an unannounced followup after having tested positive for drugs previously(49 CFR 382.605 (b)(2)(ii)).
Employers are required to keep positive test results for alcohol (0.02 or greater) and controlled substances for 5 years, even if they go out of business. They are alsorequired to retain for 5 years documentation of a driver's refusal to take a required alcoholand/or controlled substance test. Records of negative tests, canceled tests, and tests withresults of less than 0.02 must be kept for at least 1 year.
Owner-operators must comply with the drug testing regulations by implementing "a random alcohol and controlled substances testing program of two or more coveredemployees in the random testing selection pool."121 In general, owner-operators andcarriers with only a few employees may join with other owner-operators and small carriersto form a pool. The pool is then administered by a testing facility and the "randomness"consists of selection of people from that pool. Therefore, an owner-operator meets thepercentage requirements of 49 CFR 382.305 when the pool meets the requirement. Thisalso means that an owner may never be tested, yet still be in compliance. Positive resultsare reported only to the employer, who in some cases is an owner-operator.
Obtaining Past Controlled Substance and Alcohol Test Results. Drug
testing results may not be released without the permission of the driver, except to Federal,State, and local officials with authority over the employer or any of its drivers.122 Thedriver may also request the information, and it may be released as part of legal action.123 Under 49 CFR 391.21, driver applicants must provide prospective employers with a complete and accurate list of previous employers from the last 3 years.124 Applicants 120 Title 49 CFR 382.301(c)(1).
121 Title 49 CFR 382.103(b).
122 Title 49 CFR 382.405(d).
123 Title 49 CFR 382.405(g).
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must also provide prospective employers with a list of all violations of motor vehicle lawsfrom the last 3 years, as well as denials, revocations, or suspensions of licenses, permits,or privileges to operate a motor vehicle from the last 3 years.
Prospective employers are required, under 49 CFR 382.413,125 to contact each applicant's previous employers to determine whether, in the preceding 2 years, theapplicant had failed an alcohol or controlled substance test, had refused to be tested, orhad successfully completed return-to-duty requirements after having tested positive foralcohol or a controlled substance. Employers must not allow new drivers to continueperforming a safety-sensitive function after 14 days of hire without having made a goodfaith effort to obtain this information.126 Employers must record efforts made in this regardfor each driver's qualification file. Before contacting previous employers for thisinformation, employers must obtain a written authorization from each driver applicant.
According to 49 CFR 382.405(f), previous employers must release a driver's drug testing records to a new employer upon receipt of a written request from the driver.
However, there is no penalty for not complying with this regulation. The previousemployers of the New Orleans busdriver did not respond to Custom's requests for driverhistory information, despite Custom having the driver's signed permission to do so.
As will be discussed shortly, two NPRMs were recently published that propose modifications to the process by which employers obtain past drug testing informationregarding a driver. Final rules are expected later in 2001.
Past Safety Board Actions
Safety Study on Accidents Involving Drugs and Alcohol. The Safety
Board has investigated numerous commercial vehicle accidents where drivers have usedalcohol and illegal drugs (appendix J). In 1990, the Safety Board published a safety studythat focused on the role of fatigue, drugs, alcohol, and medical factors infatal-to-the-driver heavy truck crashes.127 One hundred and eighty-two accidents involving186 trucks were included in this study. From the toxicological tests, the Safety Boardfound that 33 percent of the fatally injured drivers tested positive for alcohol and otherdrugs of abuse.128 The most prevalent drugs found in drivers who had tested positive weremarijuana and alcohol (13 percent each), followed by cocaine (9 percent),methamphetamine/amphetamines (7 percent), other stimulants (5 percent), and codeineand phencyclidine (PCP) (less than 1 percent each). Stimulants (for example, cocaine and 124 Title 49 CFR 391.21(b)(10). If the driver is applying to operate a commercial vehicle that requires a CDL license, 49 CFR 391.21(b)(11) requires that the driver provide the prospective employer a list of commercial vehicle operator employers for up to 10 years.
125 Will also be required by 49 CFR 40.25, which takes effect August 2001.
126 Title 49 CFR 40.25 gives employers 30 days after hiring an employee to obtain this information. As will be discussed shortly, a new NPRM proposes to modify 382.413 to make it consistent with 49 CFR 127 Safety Study NTSB/SS-90/01, Vol. 1.
128 These drugs included over-the-counter and prescription stimulants, as well as illegal drugs such as cocaine and marijuana.
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amphetamines) were the most frequently identified drug class among fatally injured truckdrivers. As a result of this study, the Safety Board made several recommendationspertaining to drug screening and testing procedures to all levels of government, truckingassociations, and the trucking industry, including the following to the FHWA: Require preemployment alcohol and other drug tests on all drivers ofcommercial trucks with a gross vehicle weight rating of 10,000 pounds andabove as a condition of employment.
Amend 49 Code of Federal Regulations 391.21, "Application forEmployment" and 391.23, "Investigations and Inquiries," to include acomplete review of alcohol and other drug abuse treatment history prior toemployment as a commercial truck driver.
Require close supervision, including frequent, unannounced drug testing,for an appropriate period, of commercial truck drivers with an identifiedalcohol or other drug abuse problem. Such testing should be sufficientlyfrequent to create the likelihood of detection if the person uses drugs ofabuse.
In 1991, Congress passed the Omnibus Transportation Employee Testing Act, which made alcohol and drug testing a requirement for those holding a CDL. Therefore,only drivers of vehicles above 26,000 pounds are subject to preemployment testing.
Because of this Act, the Safety Board classified Safety Recommendation H-90-17 as"Closed—Acceptable Alternate Action" on April 20, 1994.
In January 1991, the FHWA responded that it planned to revise the physical examination form to include drug use treatment information, may amend the FMCSRs torequire that motor carriers release drug test results and treatment history to prospectiveemployers, and may require that prospective employers obtain this information beforeemployment or use of a driver. Consequently, on April 20, 1994, the Safety Boardclassified Safety Recommendation H-90-18 as "Closed—Acceptable Action." In February 1994, the FHWA passed the final rule for alcohol and drug testing, section 382.311, which states that a driver identified as abusing drugs or alcohol would besubject to at least six followup tests within the first 12 months upon returning to drivingduties, with additional testing possible in the following 48 months. Consequently, on April20, 1994, the Safety Board classified Safety Recommendation H-90-20 as "Closed—Acceptable Action." Commercial Driver Oversight Public Hearing, January 2000. At the Safety
Board's Commercial Driver Oversight Public Hearing in January 2000,129 severalwitnesses expressed opinions on the adequacy of drug testing procedures, including (1) Highway Accident Report
the accessibility of drug testing results, (2) driver privacy, and (3) the general effectivenessof current regulations.
Several witnesses and panelists expressed concern that positive drug testing results are inaccessible and recommended that a drug registry be created to track previouspositive drug tests. Currently, a company cannot release a former employee's drug testingresults to a prospective employer without the employee's consent. In addition, drug testsdone at the request of an employment agency or prospective employers (assuming thedriver is not hired) do not have to be released because these parties are not consideredprevious employers.
Some offered the opinion that a drug test registry might conflict with a driver's right to privacy. A representative of FMCSA stated that he believed that more people arecurrently allowed access to a driver's CDL record than are allowed access to drug andalcohol testing records, but he believed that decision makers should have as muchinformation as they can get to make an informed assessment of a driver's ability.130 Arepresentative of the National Private Truck Council stated that the rights of the individualmust be weighed against inherent public good.131 Panelists also commented on the feasibility of the drug testing system. A representative of the Owner-Operator and Independent Drivers Association, Inc., statedthat the trucking industry spends easily $600 million a year on drug testing programs, buthe knew of no evidence supporting the claim that drugs and alcohol are a problem intrucking. He further stated that the gaps in the New Orleans busdriver's employmenthistory should have been a "red flag" to the carrier that last employed him.132 Arepresentative of Coach USA voiced a different concern, stating that State laws havesometimes curtailed the company's safety efforts by prohibiting the termination ofemployees who test positive during drug tests.133 Recent Federal Initiatives
NPRM on the Safety Performance History of New Drivers. In 1996, the FHWA
published an NPRM to specify minimum safety information that new and prospectiveemployers must seek from former employers during the investigation of a driver'semployment record.134 The NPRM would modify 49 CFR Parts 382, 383, 390, and 391135to require that a motor carrier obtain a 3-year history of a driver's hours-of-service 129 Docket number DCA-00-SH002.
130 Robert Redmond, FMCSA, testimony, Commercial Driver Oversight Public Hearing, Safety Board.
131 John McQuaid, National Private Truck Council, testimony, Commercial Driver Oversight Public Hearing, Safety Board.
132 Todd Spencer, Owner-Operator and Independent Drivers Association, Inc., testimony, Commercial Driver Oversight Public Hearing, Safety Board.
133 Peter Van Beek, Coach USA, testimony, Commercial Driver Oversight Public Hearing, Safety Board.
In an April 2001 interview, Mr. Van Beek mentioned that Wisconsin and Iowa have laws that prohibit the termination of an employee after one positive drug test.
134 Safety Performance History of New Drivers, 61 FR 10548, March 14, 1996.
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violations, accident record, violations resulting in an out-of-service order, alcohol anddrug violations, and failures to undertake or complete a rehabilitation programrecommended by a substance abuse professional. Previous employers would have 30 daysto respond to a request, and drivers would have an opportunity to review and comment onthe information provided.
The FMCSA requires only previous employers that are motor carriers to provide prospective employers with drug and alcohol information. Moreover, the NPRM onlyapplies to drivers who operate commercial vehicles requiring a CDL, because only thosedrivers are subject to the drug and alcohol requirements described in Part 382. The NPRMalso recommends modifications to Part 391 that would make it easier for motor carriersthat operate commercial vehicles weighing between 10,000 and 26,000 pounds to betterdetermine the fitness of their drivers. Although such employers would not be subject to allof Part 382, it would nevertheless require them to inquire whether a prospective driver hadused a controlled substance or had failed to undertake or complete a recommendedtreatment program. These employers would not be allowed to assign a driver who hadused alcohol or drugs illegally within the past 3 years to a safety-sensitive function untilthe driver had received the recommended treatment.
According to an FMCSA representative, due to other pressing regulatory issues that have surfaced since the release of the NPRM, the FMCSA does not expect to release afinal ruling on the NPRM regarding the safety performance history of new drivers untilsometime in 2002.136 Transportation Equity Act for the 21st Century. The Transportation Equity Act
for the 21st Century (TEA-21) was enacted on June 9, 1998, as Public Law 105-178, andauthorized funding for Federal surface transportation programs in highway engineering,highway safety, and transit until the year 2003. TEA-21 also enacted new legislation oncertain aspects of highway safety. One new piece of legislation limits the liability of motorcarriers complying with regulations regarding the furnishing and use of driver safetyperformance records. 137 Regulations that will become effective August 1, 2001, willrequire motor carriers to request records showing the safety performance history of driversthey plan to hire from the former motor carrier employers of those drivers. In addition,these regulations will require former employers to furnish the requested information. Asmentioned previously, 49 CFR 391.21 and 382.405(f) already require similar, if notidentical, actions and information. However, TEA-21 addresses the fear of liability forboth former and potential employers by limiting a carrier's liability while protecting thedriver's rights and privacy.138 Motor Carrier Safety Improvement Act of 1999. The Motor Carrier Safety
Improvement Act of 1999 separated the OMC from the FHWA to create the FMCSA. It 135 Part 382 concerns controlled substance and alcohol use and testing; part 383 concerns commercial driver licensing standards; and parts 390 and 391 concern driver qualifications.
136 Valerie Height, FMCSA contact for the NPRM on the safety performance history of new drivers, telephone conversation, April 27, 2001.
137 Section 4014, which modifies 49 U.S.C. 508.
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also included several rule changes and directives. One such directive was for the Secretaryof Transportation to conduct a commercial driver drug test results study within the next 2years, to evaluate the feasibility and merits of: Requiring medical review officers or employers to report to the State thatissued the driver's CDL all verified positive controlled substances test resultson any driver subject to controlled substances testing under 49 CFR Part 382,including the identity of each person tested and each controlled substancefound, and Requiring prospective employers, before hiring any driver, to query the Statethat issued the driver's CDL for records of any verified positive controlledsubstances test on that driver. 139 NPRM on Drug and Alcohol Use and Testing. In April 2001, DOT published an
NPRM preamble140 that described the DOT's intent to make the drug testing requirementsof its six administrations conform with the new 49 CFR 40, which was published inDecember 2000.141 The preamble states that: The agencies would authorize, but not require, employers to conductpreemployment alcohol testing. However, an employer choosing to conductpreemployment alcohol testing under Federal authority must conduct it inaccordance with the 49 CFR 40 requirements.
Employers would be allowed to apply for a stand-down waiver, which wouldallow an employer to prohibit an employee from performing a safety-sensitivefunction until verification of a positive drug test result.
Employers would be required to ask individuals applying for safety-sensitivepositions whether they had ever tested positive on a preemployment test for anemployer that subsequently did not hire them. If an applicant admits that he orshe had a positive test or a refusal to test, the employer cannot use the applicantin a safety-sensitive position until successful completion of a return-to-dutyprocess is documented.
138 Public Law 105-178, Section 4014, states that, "No action or proceeding for defamation, invasion of privacy, or interference with a contract that is based on the furnishing or use of safety performance records in accordance with regulations issued by the Secretary may be brought against (1) a motor carrier requestingthe safety performance records of an individual under consideration for employment as a commercial motor vehicle driver as required by and in accordance with regulations issued by the Secretary; (2) a person who has complied with such a request…." 139 Motor Carrier Safety Improvement Act of 1999, Section 226.
140 Transportation Workplace Drug and Alcohol Testing Programs; Amendments to DOT Agency Rules Conforming to Department of Transportation Final Rule; Notices of Proposed Rulemaking; Common Preamble, 49 CFR part 382, 66 FR 21492, April 30, 2001.
141 Department of Transportation, Procedures for Transportation Workplace Drug and Alcohol Testing Programs; Final Rule, 65 FR 79462, December 19, 2000.
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A consortium or third party administrator (C/TPA) who directs anowner-operator or other self-employed individual to appear for a drug oralcohol test can make a refusal determination142 if the individual does notappear and has no legitimate reason for doing so.
The FMCSA NPRM that followed the preamble proposed changes to its drug testing procedures, as described in 49 CFR 382, to conform with the new 49 CFR 40.143The FMCSA proposed to delete from 49 CFR 382 regulatory text regarding referral,evaluation, and treatment requirements; followup testing; inquiries for alcohol andcontrolled substances information from previous employers; and SAPs. Instead, theregulations would reference the appropriate provisions of 49 CFR 40. The NPRM alsoproposes new language to address changes to preemployment testing and the stand-downwaiver provision and clarifies the regulations to allow employees to self-identify that theyhave an alcohol or drug problem without DOT consequences or penalties. A final rule isexpected in August 2001.
Recent State Initiatives
In March 2000, the State of Oregon adopted legislation to supplement and strengthen Federal drug testing requirements. Among other things, it requires that theresults of any positive drug test by an Oregon CDL driver be reported to the OregonDepartment of Transportation's Driver and Motor Vehicle Services (DMV) so it can beentered in the driver's State driving record. This includes preemployment tests.
When a medical review officer reports a positive drug test, the DMV will advise the driver of the right to a hearing. If a hearing is requested, no entry will be made on thedriver's commercial driving record pending the outcome of the hearing. Once the drug testresult is entered into a driver's driving record, it remains there for 5 years. The DMV willrelease drug test information contained on a commercial driving record only with thewritten permission of the driver.
Although this legislation was adopted early in 2000, funding problems delayed implementation of the law until September 2000.144 According to an Oregon Staterepresentative, from September 2000 to May 2001, 269 positive drug tests were reportedto the DMV, most originating from random drug tests.145 Twenty-five drivers haverequested hearings because of positive drug tests.
142 A refusal determination would cause the individual to be removed from performing a safety-sensitive function. It is proposed that such a determination by a C/TPA be reported to the DOT or to the applicable DOT agency, which in the case of commercial drivers is the FMCSA. Presumably, the DOT would enforce the appropriate action.
143 FMCSA, Controlled Substances and Alcohol Use and Testing; Notice of proposed rulemaking (NPRM); request for comments, 49 CFR part 382, 66 FR 21538, April 30, 2001.
144 Because the Oregon attorney general ruled that the State could not use highway funds to support the new regulation, MCSAP funds were eventually used.
145 Julie Santos, Driver Program Unit, Oregon Department of Transportation, electronic-mail correspondence, May 2001.
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In the New Orleans investigation, the Safety Board examined several factors that may have caused or influenced the severity of the crash, including the performance of thedriver, the vehicle, the motor carrier, the highway elements, emergency management, andsurvival factors. The Safety Board has identified several human performance issues withregard to driver medical certification and the accessibility of health history informationduring preemployment screening. In addition, survival factors and bus crashworthinessissues similar to those uncovered in a recent Safety Board report on bus crashworthinesswere also observed.146 The investigation also found a highway infrastructure inspectionand maintenance problem, although its presence did not influence the severity of thecrash. These issues will be discussed in greater detail in later sections of this analysis.
At the time of the accident, visibility was clear and the pavement dry, making it unlikely that weather contributed to the accident. Within 2 minutes of the accident,emergency management services were notified, and they responded quickly andeffectively. After the accident, Safety Board investigators inspected the motorcoach andfound no mechanical problems likely to have contributed to the accident.
The Safety Board could find no procedural or operational problems with the motor carrier. The Safety Board's evaluation of the 1996 FHWA and CSS compliance reviewsrevealed that the differences in safety rating were due to methodological differences. Thisresulted in CSS noting numerically more violations than the FHWA, although,substantially, the same violations were found.
The Safety Board evaluated Custom's actions with regard to the medical certification process to determine whether it followed the regulations and whether it couldhave done more to prevent this accident. In compliance with the regulations, Customrequired that the driver submit to a medical examination after he was physically unable tocomplete a scheduled run and after several subsequent hospital admissions. The driverpassed the physical examination, which likely indicated to Custom officials that despitetheir concerns, the driver was physically fit enough to drive under the Federal regulations.
Custom officials did not have a medical background and had no reason to doubt theconclusions of the examiner, especially since the Federal regulations state that allcommercial driver examiners must be knowledgeable of the physical and mental demandsassociated with operating a commercial vehicle, must be knowledgeable of the regulationspertaining to driver fitness, and must be proficient in the use of the medical protocolsnecessary to adequately perform a commercial driver medical examination. Custom 146 National Transportation Safety Board, Bus Crashworthiness Issues, Highway Special Investigation Report NTSB/SIR-99/04 (Washington, DC: NTSB, 1999).
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clearly relied on the knowledge and opinion of the commercial driver examiner todetermine whether the New Orleans driver was physically fit enough to continue driving.
The Safety Board believes that it might have been possible for Custom to better monitor the driver's absences, frequency of medical appointments, and observed medicalsymptoms to make further evaluations on his health. However, in the Safety Board'sopinion, given the current state of the medical certification system, there was little thatCustom could have done differently to avert the accident.
Custom complied with the Federal regulations pertaining to drug testing. The driver underwent one preemployment and three random drug tests while with Custom, andall tests were negative for drugs. It also attempted to obtain information about the driverfrom previous employers, but received no responses. Even had Custom persisted andeventually obtained information about the driver from a former employer, the informationobtained would probably not have been useful in making a hiring decision since the driveronly listed former employers that had not fired him for positive drug test results.
Therefore, the Safety Board concludes that the mechanical condition of the bus, the weather, emergency management, and motor carrier management did not contribute toor influence the severity of the accident.
The remainder of this analysis will address the medical certification, drug testing, bus crashworthiness, and highway issues identified during the investigation.
The Accident
The driver did not have control of the bus before the accident, resulting in the bus departing the right side of the roadway, striking the terminal end of a guardrail, travelingthrough a chain link fence, vaulting over a paved golf cart path, and colliding with the farside of a dirt embankment. Several pieces of evidence point to incapacitation as the reasonthe driver failed to maintain control of the bus. First, one of the witnesses, who had been ina van behind the motorcoach, stated that the bus initially drifted towards the center laneand almost hit a small green car, but then drifted back to the middle of the left lane.
Shortly after this, the bus left its lane and departed the side of the road. She stated that thebus was not out of control, did not have its brakes applied, and did not waiver or swerve inany direction.
These observations of the motorcoach correspond with an eyewitness account by one of the bus passengers regarding the driver. According to this passenger, she recalledseeing the busdriver "slouch down," as if reaching for a soda. He came back up, but thenwent down again. The next thing she remembered was waking up in the hospital.
Postaccident toxicology tests of the driver revealed that the driver had used marijuana sometime before going on duty, which could have led to a loss of coordination,lethargy, and problem-solving difficulties. Diphenhydramine, a drug with both sedating Highway Accident Report
and performance-impairing effects, was also found in his blood. In addition, due to hishospitalization the night before, the driver spent only 6 hours at home before leaving forwork. These factors suggest that the driver may have been fatigued before the crash.
However, although the driver's health condition was likely exacerbated by the effects ofmarijuana and a sedating antihistamine, the witness' descriptions of the driver's actionsand the bus' motion suggest medically related incapacitation, rather than falling asleep atthe wheel, as the probable cause of this accident.
The observed behavior of the driver prior to the accident is consistent with his experiencing a significant reduction in blood flow to the brain, resulting in an impairmentof consciousness. Consciousness was likely restored when the driver's head descended toa level below that of his heart. When the driver resumed an erect posture, with his headonce again above the level of his heart, this likely led to a repeated reduction orinterruption of blood flow to his brain, again leading to a loss of consciousness fromwhich the driver did not recover until after the accident. The witnesses' description is lessconsistent with fatigue and falling asleep at the wheel, actions that are more associatedwith head nodding than a gross loss of body posture.147 The driver had several serious medical conditions, any of which could have caused a reduction or interruption of blood flow to the brain. Congestive heart failure is, bydefinition, an inability of the heart to maintain an adequate output of blood, and the driverhad a history of recurrent episodes of congestive heart failure as a result of his dilatedcardiomyopathy. In addition, cardiac arrest is common in individuals with dilatedcardiomyopathy, frequently as a result of an abnormal heart rhythm, and the driver hadexperienced such abnormal heart rhythms without warning on previous occasions. Finally,dialysis treatment itself can leave an individual susceptible to episodes of low bloodpressure (such as that experienced by the driver the night before the accident). This ismade more likely with his use of medication, such as metoprolol, which reduces thecapability of even a normal heart to compensate for reduced blood pressure.
The Medical Certification Process
The bus driver involved in the New Orleans accident had serious medical conditions that should have called into question his ability to safely operate a commercialvehicle. In this case, as in the Central Bridge accident and in the other accidentssummarized in appendix H, the certification system failed to ensure even a cursoryevaluation of the drivers' medical conditions. In those investigations, evidence wasavailable to the examiners suggesting that such an evaluation was necessary to determinethe fitness of the drivers.
147 Physiological characteristics associated with fatigue include eyelid droop, blink frequency, head nodding, microsleep, and changes in electroencephalograph (EEG) readings. Studies have not mentioned a loss of body posture as a symptom of fatigue. From D.F. Dinges and M.M. Mallis, "Managing fatigue bydrowsiness detection: Can technological promises be realized?," L. Hartley, ed., Managing Fatigue in Transportation (Oxford, U.K.: Pergamon) 209-229 and J.C. Stutts, Sleep Deprivation Countermeasures for Motorist Safety, NCHRP Synthesis 287 (Washington, DC: National Academy Press).
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Federal regulations dictate the criteria by which interstate commercial drivers may be certified as medically fit to drive. Federal oversight of the biennial medical certificationprocess conducted for an estimated 9 million licensed commercial vehicle drivers isaccomplished almost exclusively by three full-time individuals in the FMCSA. Stateoversight of the medical certification process for interstate drivers is not mandated byFederal regulations, and the decision to certify a driver as fit to drive typically rests withthe individual examiner performing the physical examination on the driver.
Medical Certification Process Issues
Despite suffering from potentially incapacitating medical conditions, the driver involved in the New Orleans accident was able to obtain a medical certificate by falsifyingand omitting crucial health history information from the examination form. Even thoughthe examiner was able to determine that the driver had heart disease, and possibly kidneydisease, she believed that the available FMCSA guidance was insufficient to deny thedriver a current medical certificate. Although several of the driver's physicians wereaware of the driver's profession and were also aware of the seriousness of his illnesses,none reported their concerns to the State licensing agency. Other serious flaws foundduring the course of this investigation, and during the Safety Board's driver oversighthearing, called into question the effectiveness of the entire medical certification process.
The following section of the analysis describes the limitations of the current certification process, including: Adequacy of examiner qualifications.
Adequacy of the Federal regulations.
Adequacy and availability of nonregulatory guidance.
Lack of a review process.
Lack of a tracking mechanism for medical certification exams.
Role of other responsible parties.
Lack of strong certification enforcement.
Accessibility of driver health history information.
Adequacy of Examiner Qualifications
The New Orleans driver received medical certification without a specialized or detailed medical evaluation, despite a history of serious disease. This was also true of thedriver in the Central Bridge accident and of the drivers in the 15 other incidents noted inappendix H. Further instances of unfit drivers who obtained medical certificates are givenin the Safety Board's 1990 report on fatigue, alcohol, other drugs, and medical factors infatal-to-the-driver heavy truck crashes.148 The Safety Board therefore concludes that the 148 Safety Study NTSB/SS-90/01, Vol. 2.
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failure of the medical certification process to remove unfit drivers is a systemic, not anisolated, problem. Although the Federal regulations require medical examiners to be familiar with the physical and mental demands facing commercial drivers, the instructions that generallyaccompany the old examination form do not describe these demands. In addition, there areno training or certification courses for examiners, so it is unclear how familiar the NewOrleans and Central Bridge examiners were with these demands. The new medicalexamination form should make it easier for examiners to become familiar with some ofthe demands of operating a commercial vehicle. However, the Safety Board is stillconcerned that some examiners might not possess the skills or background necessary toevaluate common medical problems facing commercial vehicle drivers.
An example of this concern is the inability of most chiropractors, who may serve as examiners in many States, to assess the possible effects of prescription drugs,nonprescription drugs, and drug interactions on commercial vehicle operators. Thepractice of chiropractic medicine specifically avoids the use of medications; chiropractorstypically receive no formal training in pharmacology and are not licensed to prescribemedication. It is therefore unreasonable to expect that most doctors of chiropractic wouldknow how certain medications affect driving performance.
The FAA's medical certification program stands in contrast to that for commercial drivers in both examiner qualifications and skills. All AMEs participating in the programare physicians, who must attend a 1-week seminar on the FAA's medical certificationprogram and take a refresher course every 3 years. In addition, they are kept abreast ofnew regulations and guidelines through a quarterly newsletter.
Since not all commercial driver examiners have a background in drugs and drug interactions, or are familiar with the mental and physical demands of commercial driving,or are knowledgeable about the regulations and accompanying guidance material, theBoard concludes that individuals who are authorized to perform medical examinations andcertify commercial drivers as fit to drive may lack knowledge and information critical tocertification decisions. Consequently, drivers with serious medical conditions may not beevaluated sufficiently to determine whether their condition poses a risk to highway safety. Adequacy of the Federal Regulations
The accident driver had been diagnosed with kidney failure in July 1998 and had been receiving hemodialysis since December of that year. His medical records indicatethat he failed to show up for dialysis treatments at least four times and that he terminatedtreatment prematurely on two occasions. One such occasion occurred the night before theaccident, when the driver terminated hemodialysis treatment prematurely against medicaladvice. Although a person with kidney failure that is well controlled may experience few,if any, debilitating effects from the disease, a person with poorly controlled kidney failurecan suffer symptoms ranging from fatigue and dizziness to seizures and coma.
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Kidney failure and other potentially debilitating diseases are not directly addressed in the regulations regarding the medical certification of commercial drivers, although thehealth history section of the medical examination form does provide a check box forkidney disease. A general clause requires disqualification for "any other condition, whichis likely to cause loss of consciousness or any loss of ability to control a commercial motorvehicle,"149 but this requires the examiner to make a subjective assessment of the driver'scondition. Thus for a driver with significant diseases such as kidney failure, liver failure,breast cancer, gastrointestinal disease, or malignant melanoma, the regulations do notprovide the examiner with specific, unambiguous language on which to deny medicalcertification. In addition, the regulations state that an examiner shall "be knowledgeable ofthe specific physical and mental demands associated with operating a commercial motorvehicle…,"150 but they do not define what constitutes "being knowledgeable." One of the primary reasons for the new commercial driver examination form was to have it better reflect current medical knowledge, terminology, and practice. Yet the newform is still based on regulations that have not been updated substantially in 30 years.151As a result, the form and the regulations do not reflect new knowledge in areas such asmonocular vision (problems affecting one eye), kidney disease, sleep apnea, and fatigue.
Strict application of the regulations could result in the disqualification of fit drivers andthe certification of unfit drivers. Furthermore, examiners may be hampered in their abilityto disqualify drivers that have medical problems mentioned in the new examination formbut not specifically covered in the current regulations.
Although the FAA's medical fitness and certification criteria for airmen can appear as nonspecific as the criteria for commercial drivers (for example, kidney disease andcancer are also not specifically mentioned), the medical certification rules and proceduresin place at the FAA make this less of a concern. For example, AMEs must also undergocertification training, are given a handbook containing examination procedures andguidance material, and are apprised of changes to the regulations and guidelines through aquarterly medical bulletin. In addition, examination forms are reviewed to better ensurethat all certified airmen meet a consistent level of fitness.
In contrast, commercial driver examiners are not required to attend a training or certification program, are not given a handbook of examination procedures, and do notreceive regular updates of guidance information. Examination forms are not reviewed forcompleteness or consistency with the regulations and guidance information. Factors suchas these make it all the more important that the regulations on commercial driver fitness beupdated to reflect current knowledge and include more specific information on potentiallydisqualifying conditions.
149 Title 49 CFR 391.41(b)(8).
150 Title 49 CFR 391.43(c)(1).
151 In contrast, the "Medical Standards for Drivers" section of Canada's National Safety Code, which has been voluntarily adopted by the provincial and territory licensing agencies as the minimum fitness requirement for drivers, is reviewed every 2 years by physicians representing each province and territory to keep it current with the medical literature.
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As the New Orleans accident clearly demonstrated, the regulations, as written, often do not permit examiners to determine whether drivers with common, potentiallydebilitating medical conditions should be issued a medical certificate. Coupled with thelack of certification training and the lack of knowledge about available guidance, thiscould result in some examiners incorrectly certifying unfit drivers. The Safety Boardconcludes that the regulations on the medical certification of commercial drivers do notreflect current medical knowledge and information and can be ambiguous regarding theconditions that may constitute disqualification.
Adequacy and Availability of Nonregulatory Guidance
Although the FMCSA had medical guidance information available on its Web site at the time of the New Orleans accident and provided guidance material to examiners whocontacted its staff, the New Orleans examiner was apparently unaware of the additionalguidance material. As a result, she may not have had the information she needed toadequately judge the health of the accident driver. The New Orleans crash clearlyillustrates that some examiners may lack the proper resources to judge the fitness level ofcommercial vehicle drivers and may not know where to obtain it.
During the Safety Board's Commercial Driver Oversight Public Hearing, one witness testified that although examiners are expected to be knowledgeable of theregulations and guidance regarding commercial drivers and of the physical and mentalrequirements of the profession, some examiners do not know that the regulations orguidance exists.152 Further, even examiners who are aware of the regulations and guidancemay not be aware of new information or changes to the material. The witness cited a studyby the AAAM monitoring the performance of examiners, which indicated that, in someStates, nearly half of the exams were done incorrectly.153 Although not a Federal requirement, the old commercial driver physical examination forms normally include instructions on the back regarding how to performand record the medical examination. The new form created by the final rule publishedOctober 2000 includes a more thorough health history section that also prompts the driverto provide information on medication use. It contains the instructions and guidelines nextto each item in the medical evaluation section, a section describing the type of duties that adriver might face as a result of his/her employment and an attached section containing thepertinent regulations and detailed instructions. However, because these instructions andguidelines are not a required part of the medical examination form, the possibility stillexists that not all examiners will benefit from having this information. In addition, thefinal rule published in October 2000 notes that "existing forms may be used untilNovember 6, 2001." The old form is not as informative and the Safety Board is uncertainhow this "sunset date" for the old form will be enforced, since no Federal requirementexists for anyone other than the examiner to see the form.
152 Dr. Natalie Hartenbaum, Occumedix, testimony, Commercial Driver Oversight Public Hearing, Safety Board.
153 Association for the Advancement of Automotive Medicine, Prototype State Medical Review Program: Final Report, DTFH 61-90-C-00098 (Washington, D.C.: Federal Highway Administration, 1995).
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Nevertheless, the Safety Board is encouraged by the progress that is being made to make the guidance information more accessible and to inform examiners of theoccupational hazards of commercial driving. Under most situations, the medicalexamination instructions included with the new form may provide a satisfactory amountof information for examiners to evaluate drivers properly and a source of individualizedguidance when available. Therefore, the Safety Board concludes that the new medicalcertification form for commercial drivers is a substantial improvement over the previousversion and, if used in its entirety and in conjunction with attached instructions, will aidexaminers in making certification decisions. During the Safety Board's Commercial Driver Oversight Public Hearing, a witness stated that FMCSA staff members are "receptive and available for questions and guidancewhen an examiner knows to call them."154 The FMCSA has made the medical advisorycriteria available on its Web site and has included the criteria in the instructions for thenew form, along with a telephone number. However, the FMCSA Driver and CarrierOperations Division has only one part-time and two full-time registered nurses on themedical team, who manage virtually the entire interstate medical certification process foran estimated 9 million commercial vehicle drivers.
The Safety Board is encouraged by the attempts of the FMCSA to increase the dissemination of guidance to potential examiners through its Web site and the newmedical examination form. However, the New Orleans accident, as well as otherinvestigations that the Safety Board has conducted, have demonstrated that not allexaminers are aware of such information. The Safety Board concludes that not allindividuals who are authorized to perform medical examinations and certify commercialdrivers as fit to drive are made aware of information sources that could assist them withcertification decisions. Lack of a Review Process
The medical examination forms completed for the drivers in the New Orleans and Central Bridge crashes noted significant medical histories, but received no furtherevaluation. The examiner of the New Orleans driver said that the driver was onmedications for congestive heart failure, but she did not require further evaluation ordisqualify him from driving. In the Central Bridge case, the physician noted the driver'sdiabetes and his history of angioplasty, but she did not require a twice-yearly reevaluationof his diabetes, as mandated by State regulations, or additional evaluations of the driver'sheart condition. In addition, the Central Bridge driver did not complete the driver's historysection of his examination form, possibly allowing him to avoid questions about his heartcondition.
The current Federal medical certification program does not require that medical certificates or examination forms be reviewed by State licensing authorities or others onceissued. A review process might have led to the detection of the inconsistencies andomissions present on the Central Bridge and New Orleans medical examination forms.
154 Dr. Natalie Hartenbaum, testimony, Commercial Driver Oversight Public Hearing, Safety Board.
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Concerns regarding the lack of a review process prompted the FHWA to require the sixStates participating in its pilot study to collect and review the medical examination formsof commercial vehicle drivers as part of the study. This requirement gave the Statelicensing authorities an opportunity to monitor the fitness of commercial drivers at thetime of license application or renewal. Secondly, it allowed the licensing authorities toevaluate the quality of the medical certification process and the completeness andaccuracy of the medical form. The results of the pilot program showed that the reviewsuncovered several incomplete or otherwise unacceptable examination forms. The reviewsalso identified a number of applicants who did not meet the Federal or State fitnessstandards and who were subsequently disqualified. It is likely that these applicants wouldhave obtained their CDLs and would have continued driving under the current Federalmedical certification program.
The NPRM for merging the CDL and the medical certificate, which is expected in 2002, is anticipated to propose several sweeping changes aimed at creating a morecomplete driver and examiner oversight system. The Safety Board is encouraged by theresults of the pilot tests that drove the release of the ANPRM and the formation of aNegotiated Rulemaking Advisory Committee and hopes that the FMCSA moves quicklyand aggressively towards enacting a complete and effective medical certification system.
Louisiana does have a review process. Licensing agencies in the State review and track the latest medical examination form of drivers who are renewing their CDLs.
However, because Louisiana requires that the CDL be renewed every 4 years, compared toevery 2 years for the medical certificate, only every other medical examination form isreviewed and tracked by the licensing agency. The driver involved in the New Orleansaccident renewed his CDL in November 1995 and submitted his latest medicalexamination form at that time. His health apparently began deteriorating after his last CDLrenewal.155 Since he was not scheduled to renew his CDL until November 1999, thelicensing agency did not have the results of his April 1998 and August 1998 commercialvehicle driver physicals.
In comparison, California, Arizona, and Hawaii currently require that commercial drivers of vehicles heavier than 10,000 pounds submit their full medical examination formto the licensing agency for review and tracking. California and Arizona require that theform be submitted every 2 years, whereas Hawaii requires that the form be turned induring CDL issuance, renewal, or transfer.156 The District of Columbia and Indiana requirethat CDL holders submit the examination form every 2 years for review and tracking.
Nevada requires intrastate CDL drivers to submit their examination forms.157 At least 11 155 The busdriver's August 1997 medical records indicate that the busdriver had a 2-year history of high blood pressure and borderline diabetes.
156 In Hawaii, a CDL is current for 6 years.
157 From the Association for the Advancement of Automotive Medicine's 1997 report to the FHWA, Update of Medical Review Practices and Procedures in U.S. and Canadian Commercial Driver LicensingPrograms. Wyoming requires that an examination form be submitted if it is known that a driver has a medical condition that might potentially impair his/her driving. Review and tracking information was not obtained for Alabama, Alaska, Oklahoma, and Pennsylvania.
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other States require drivers to submit a copy of their medical certificates to the licensingagency (see appendix D), but because the certificate only contains waiver information andthe examiner's endorsement and not the actual examination results, a full verification ofthe information that resulted in the certification is not possible.
One of the most telling pieces of information about the New Orleans driver's last medical examination was the date it was performed. Although the driver had a currentmedical certificate, his condition was such that Custom nevertheless required him to haveanother examination performed. Had this form been submitted to the State for review, theshortened renewal cycle would probably have been noticed and might have resulted infurther scrutiny. Although a few States collect and review commercial driver examinationforms more frequently than Louisiana, none has a system in place that could identifywhether a driver had an examination performed within the 2-year medical certificationcycle. The swift deterioration of the New Orleans driver's medical condition illustratesthat such a system is necessary for a reviewing agency to identify drivers who arepotentially unfit. The FAA has such a system in place, with AMEs submitting everyexamination form to the Division of Aeromedical Certification. Therefore, the SafetyBoard concludes that the absence of a process under which every driver medicalexamination form is reviewed greatly increases the likelihood that medical certificateswill be issued inappropriately, thereby allowing medically unqualified commercial vehicledrivers to continue driving. Other characteristics of the current commercial driver medical certification system support the need for a review process. During a commercial driver examination,examiners are placed in the difficult position of disqualifying some drivers, therebydepriving the drivers of their livelihood. This can be especially difficult for examinerswho are also the drivers' personal physicians. In addition, fear of legal action from driversmay exert further pressure on examiners to certify drivers with serious conditions that theregulations do not clearly establish as disqualifying, instead of requiring additionalevaluation or disqualifying such drivers. A system of comprehensive review couldeliminate some of the pressure on examiners, potentially allowing them to defer difficultcases; the FAA does this in its medical certification process. Finally, any agencydesignated to review medical examinations could serve as an effective source of guidancefor examiners who have questions about a particular applicant.
The Lack of a Tracking Mechanism for Medical Certification Exams
When filling out his examination form, the New Orleans busdriver did not complete the health history section truthfully. In the check boxes provided, the driverindicated that he did not have a history of kidney or cardiovascular disease. He also toldthe examiner that he did not suffer from heart problems. When the examiner askedwhether he was taking any medication, his response prompted her to ask him about heartproblems again. Only then did he tell her that he indeed had a history of high bloodpressure and congestive heart failure. The busdriver involved in the Central Bridgeaccident also failed to disclose his medical condition to the examiner. In the health historysection of the examination form, the driver failed to indicate (either "yes" or "no")whether he had a history of high blood pressure, heart disease, or vision problems. In Highway Accident Report
addition, the driver failed to note past treatments for congestive heart failure and did notlist his cardiac medications or his blood thinner. Any of this information might havehelped the physician better establish the seriousness of the driver's medical conditions.
In each of these cases, the examiner issued the driver a medical certificate.
However, even had the examiner denied the medical certificate, no regulation ormechanism existed to prevent the driver from simply visiting another examiner. Becausesuch visits are not tracked, it is impossible to know whether a driver has, in fact, beendenied medical certification by another examiner.
The potential for an unfit driver to visit multiple examiners until one is found that will certify his or her health was a concern voiced by both physicians and licensingadministrators during the Commercial Driver Oversight Public Hearing. "Doctorshopping" is possible because the current Federal regulations do not require examiners tocontact a driver's employer or the State licensing authority if a driver is found medicallyunqualified to operate a commercial vehicle.158 Therefore, only the driver and thatadministering examiner know whether the driver passed the fitness exam. Again, becauseof the lack of a tracking mechanism, the frequency of "doctor shopping" cannot beestimated reliably, but there are several reports of its occurrence.159 The Safety Boardtherefore concludes that, in the absence of a mechanism to track all medical certificationexaminations, a commercial driver with a serious medical condition who is denied amedical certificate by one examiner may be able to obtain a medical certificate fromanother examiner, thus subverting the purpose of the medical certification process. The current medical certification process for commercial vehicle drivers stands in contrast to the FAA's certification system. The examination form used by the FAA can beobtained only through the Division of Aeromedical Certification. Each form is stampedwith a unique number and must eventually be turned into the division regardless ofwhether it is used for an examination (for example, even if an examiner spills coffee onthe form, making it unusable, it must still be turned in). In addition, the FAA maintains aregistry of AMEs. The FAA also verifies, reviews, and tracks the information on everyexamination form. By tracking each form and by reviewing and maintaining a registry ofexaminers, the FAA has effectively eliminated the threat of "doctor shopping." The Role of Other Responsible Parties
The need for guidance extends beyond examiners to other health care professionals and individuals who may encounter commercial vehicle drivers betweenphysical examinations. In the 2 years before the accident, several physicians and health 158 Dr. Natalie Hartenbaum testified that examiners at American College of Occupational and Environmental Medicine (ACOEM) seminars on DOT medical certification frequently asked whom they should notify upon examining a driver not meeting fitness requirements. (National Transportation Safety Board public hearing, Highway Transportation Safety Aspects of the North American Free TradeAgreement, Los Angeles, California, October 20 through 22, 1999.) 159 Some sources describing incidences of "doctor shopping" are N.P. Hartenbaum, The DOT Medical Examination (OEM Press: USA, 1997); S. Twedt, "Rigged for Disaster," Pittsburgh Post Gazette, January 16, 2000; and testimony, Commercial Driver Oversight Public Hearing, Safety Board.
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care providers treated the New Orleans busdriver for heart failure and kidney failure. Thedriver was in the hospital as often as six times a week for hemodialysis treatment anddobutamine therapy. Many of them knew the busdriver's profession, but apparently no oneattempted to contact his employer or the State licensing authority concerning thebusdriver's fitness to operate a commercial vehicle. Louisiana has a procedure in place forphysicians to report unfit drivers; as mentioned previously, it also offers immunity fromcriminal or civil action to any health care provider who files such reports in good faith.
In August 1998, Custom required the driver to have a medical examination because of concerns about his fitness to operate a bus. However, Custom did not, and wasnot required to, report his condition to any regulatory authority. The health care providersthat treated the driver during his frequent visits to the hospital knew he was a busdriverand were aware of his life-threatening medical conditions, but none reported, or wererequired to report, any concerns they might have had to any regulatory authority or to thedriver's employer. Similarly, the personal physician of the driver involved in the CentralBridge accident had expressed serious concerns about the driver's condition andmedication adversely impacting his ability to safely perform his job, but was not requiredto report his concerns, and apparently discussed them only with the driver. The SafetyBoard concludes that many drivers whose occupations and serious medical conditions areknown to their employers, health care providers, and others are never reported, therebypotentially endangering the drivers themselves and others. Although Louisiana has an immunity law that protects physicians who report unfit drivers, it does not have one for other people who report unfit drivers in good faith. Asshown in appendix G, at least 19 States do not offer immunity to physicians, and at least 30do not offer immunity to those who report an unfit driver in good faith but are notphysicians. Because of the critical importance of such reports in ensuring highway safety,the Safety Board believes that the National Conference of State Legislatures160 shouldinform State legislatures about this accident and make them aware of the importance ofestablishing immunity laws for the good-faith reporting of potentially impairedcommercial drivers by all individuals and of ensuring that the medical community and thecommercial transportation industry are familiar with these laws. Lack of Strong Certification Enforcement
During his medical examination in August 1998, the New Orleans driver attempted to mislead the examining physician by stating in the health history section ofthe examination form that he did not have cardiovascular disease or kidney disease. Thedriver's actions indicated that he clearly understood a full disclosure of his conditionswould likely lead to a denial of his medical certification. However, it is also clear from thedriver's actions that the penalties for intentionally making false statements on theexamination form were either not known to the driver or did not serve as an effective 160 The National Conference of State Legislatures provides State lawmakers with research and consulting services, publications, meetings, and seminars. The organization's Web site<http://www.ncsl.org> states that the organization serves as a conduit for State lawmakers to communicate with one another and share ideas and assists States in representing their common interests before Congress, the administration, and Federal agencies.
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deterrent. The driver may have also known that an enforcement action was remote, giventhat this examination form did not need to be submitted to the Louisiana Division ofMotor Vehicles.
According to 49 CFR 390.37, making fraudulent or false statements on any application, certificate, report, or record described in that particular subchapter of theregulations (such as the commercial driver medical examination form) may result in civilor criminal penalties. As noted previously, the regulations do not mention any otherpenalties that apply specifically to the falsification of the medical examination form, suchas the revocation of the medical certificate or the suspension of a driver's CDL. The datacompiled by the FMCSA on enforcement action only mention monetary penalties. Dataare not readily available regarding whether any of the cited drivers had their medicalcertificate revoked or their license suspended or were disqualified from driving. Thiscontrasts with the regulations that apply to the FAA's medical examination form, forwhich there are specific penalties for making intentionally false statements. Airmen foundto have made intentionally false statements on the form could have their licenses revokedif the FAA considers the offense serious.
During their investigations, Safety Board investigators have occasionally encountered a driver who was carrying a forged medical certificate, such as in the Walker,California, and Middletown, New Jersey crashes (see appendix H). This is possiblebecause the examination form is readily available from a variety of sources (for example,the new certificate and form can be ordered from a vendor), and no procedure orinformation source exists to validate the medical certificate itself or the name of theexaminer who signed it.
The absence of a procedure or information source to determine the validity of a current medical certificate has limited the effectiveness of MCSAP safety inspections. Asnoted previously, in most cases, MCSAP safety inspectors only check whether a driver hasa current medical certificate, whether a driver meets medical exemption requirements, andwhether the carrier has included a current copy of a driver's medical certificate in the file.
In most cases, inspectors can only determine whether a driver is unfit to operate acommercial vehicle when the driver clearly requires a medical exemption but does nothave one; it is not surprising that only the lack of a proper SPE certificate or exemption, orthe absence of corrective lenses or a hearing aid when one is required by a driver'smedical certificate, can result in the driver being placed out of service under Federallaw.161, 162 Some States, such as California and Arizona, not only review and track commercial driver examination forms, but have also merged the CDL with the medicalcertificate. Both California and Arizona allow the licensing agency to disqualify acommercial driver if the driver does not posses a current medical examination form or ifthe agency has concerns about the accuracy or completeness of the form. Because law 161 North American Standard Out-Of-Service Criteria, 2001.
162 State laws may include other violations that could result in the driver being placed out of service.
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enforcement officers in these States are able to check on a driver's license status duringinspections and routine stops, they are able to prevent disqualified drivers from driving,effectively keeping potentially unfit drivers from operating commercial vehicles.
Unfortunately, this enforcement program works only for commercial drivers licensed inCalifornia and Arizona, because most other States have not implemented a medicalexamination form review process and have not linked driver fitness with the CDL.
The Safety Board concludes that enforcement authorities cannot, in most instances, determine the validity of a medical certificate during safety inspections androutine stops because of the absence of procedures or information sources to validate themedical certificate itself. The Safety Board further concludes that the inability toauthenticate the information on a medical certificate hampers enforcement authorities intheir ability to identify unfit drivers and place them out of service. Toward an Effective Medical Certification Program
Based on the New Orleans accident and on other accidents involving drivers with known serious medical conditions who were still able to obtain medical certificates, theSafety Board finds a number of elements to be critical to the establishment of an effectivemedical certification program for commercial drivers, as discussed below: Qualified Examiners. Examiners should have specific training for performing
examinations to determine the fitness of commercial drivers; in addition, examinersrequired to be the certifying authority should have a background permitting them toadequately evaluate all common medical conditions or medications for their potential toimpair a driver.
Medical Certification Regulations. The regulations are updated regularly to
permit trained examiners to clearly determine whether to issue a medical certificate todrivers with certain common medical conditions.
Adequate Guidance. Potential examiners should receive guidance that permits
them to perform a physical examination adequate for making informed certificationdecisions on a commercial driver. Examiners, if required to be the certifying authority, aregiven guidance regarding the certification of medical conditions not covered by theregulations. Examiners should have a readily identifiable source of information forspecific questions in which the guidance may be inadequate.
Review Process. Completed examination forms should undergo at least one
review by a trained individual other than the examiner so that certifications issued in errorare corrected or prevented. All applications or completed medical examinations oncommercial drivers are recorded and reviewed so that comparisons may be made of everysubsequent application or examination. This comparison ensures that significant changesin medical information provided through the medical certification system can beadequately evaluated.
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Identification of Invalid Certification. Law enforcement will be able to establish,
during safety inspections and routine stops, that a commercial driver's medicalcertification is valid.
Removal of Uncertified Drivers. Upon determining the validity of a certificate,
law enforcement can disqualify a driver from operating a commercial vehicle. The driverwill not be permitted to return to commercial driving until receiving a medical evaluationthat establishes that the driver has no potentially impairing or incapacitating medicalcondition.
Reporting of Medical Conditions. Drivers who are found by their employers,
their health care providers, or others to have developed a potentially impairing orincapacitating condition between required medical certification examinations will bereported to the appropriate regulatory authority. All potential reporters of such informationare aware of and are able to utilize procedures for such reports. All medical conditionsdiscovered through such a reporting process will be adequately evaluated.
The severity of the New Orleans busdriver's medical condition might have been rare, but the situation is not unique. The ease in which the current medical certificationprocedures can be bypassed virtually assures that some unfit drivers will find their waybehind the wheel of a commercial vehicle, endangering themselves and the motoringpublic. To curb this danger and to better accomplish the intent of the medical certificationprocess, the Safety Board believes that the FMCSA should develop a comprehensivemedical oversight program for interstate commercial drivers that contains the followingprogram elements: Individuals performing medical examinations for drivers are qualified to do soand are educated about occupational issues for drivers.
A tracking mechanism is established that ensures that every prior applicationby an individual for medical certification is recorded and reviewed.
Medical certification regulations are updated periodically to permit trainedexaminers to clearly determine whether drivers with common medicalconditions should be issued a medical certificate.
Individuals performing examinations have specific guidance and a readilyidentifiable source of information for questions on such examinations.
The review process prevents, or identifies and corrects, the inappropriateissuance of medical certification.
Enforcement authorities can identify invalid medical certification during safetyinspections and routine stops.
Enforcement authorities can prevent an uncertified driver from driving until anappropriate medical examination takes place.
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Mechanisms for reporting medical conditions to the medical certification andreviewing authority and for evaluating these conditions between medicalcertification exams are in place; individuals, health care providers, andemployers are aware of these mechanisms. The Safety Board is aware that all of the State licensing agencies have adopted the Federal requirements for interstate commercial driver fitness for their intrastatecommercial drivers. The Board recognizes that the issues discussed here apply fully tointrastate drivers as well. The American Association of Motor Vehicle Administrators(AAMVA) represents State and provincial officials in the United States and Canada whoadminister and enforce laws pertaining to the motor vehicle and its use. The programsadministered by the AAMVA, such as the Commercial Driver License InformationSystem and the International Registration Plan,163 encourage uniformity and reciprocityamong the States, other levels of government, and the private sector. The Safety Boardrecommends that AAMVA urge its member States to develop a comprehensive medicaloversight program for intrastate commercial drivers containing the features discussed inthe recommendation to the FMCSA. Drug Testing Procedures
When the New Orleans driver applied for the position at Custom, he listed his former positions with Hertz Car Rental and Turner's Bus Service, but did not mentionpositions held with The Regional Transit Authority and with Westside Bus Service, wherehe had been dismissed for testing positive for marijuana. He explained the gaps in hisemployment record by stating that he was a musician in a brass band during those times.
Custom sent requests for information to both Hertz Car Rental and Turner's Bus Service, both of which were authorized by the busdriver. However, Custom did not receivea response from either company. While with Custom, the driver underwent apreemployment and three random drug tests during his tenure with negative results.
Three problems are evident from the events described above. First, the driver was able to avoid negative scrutiny from Custom by omitting parts of his employment history.
Second, although Custom obtained the driver's permission to investigate his employmenthistory, it did not receive a response from any of the former employers it contacted. Third,no enforcement mechanism or incentive exists to compel previous employers to complywith information requests.
Although the 1996 NPRM on new driver safety performance history proposes that prospective employers expand their inquiries into a driver's background, it is still possiblefor drivers to hide positive drug test results in the manner of the New Orleans driver. Title49 CFR 391.21 requires drivers to provide carriers with the names and addresses ofemployers from their previous 3 years of employment, including their employment dates 163 See <http://www.aamva.org> for an explanation of these programs.
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and reasons for leaving. However, drivers are unlikely to provide such history when itmight limit their opportunities for employment. Additionally, enforcing this requirement isdifficult because the only way to detect a false employment history would be to obtainemployment information from someone other than the driver.
The April 2001 NPRM on workplace drug and alcohol testing programs issued by the FMCSA proposes that employers ask individuals applying for safety-sensitivepositions whether, in the past 2 years, they had ever tested positive on, or had refused totest for, any preemployment drug or alcohol test administered by an employer whosubsequently did not hire them. The Safety Board does not believe this self-reportingmethod will effectively identify problem drivers because drivers are unlikely to provideinformation that may limit their employment opportunities. Because employees areunlikely to divulge positive drug test results and because prospective employers may nothave sufficient employment history or the authority to obtain information from previousemployers regarding positive drug tests, the Safety Board concludes that results of testsfor controlled substances performed under the DOT testing guidelines, even whenpositive, are often not available to prospective employers, making it difficult for them tomake well-informed hiring decisions. Drivers who own and operate their own commercial vehicles (owner-operators) are required by the regulations to comply with all the requirements stipulated for bothdrivers and employers. Owner-operators are thus in the precarious position of overseeingtheir own substance abuse program. No Federal requirements exist for reporting driverswho have tested positive for controlled substances to any regulatory or certifyingauthority. Therefore, the only entity with information regarding a positive test is theemployer, who, if an owner-operator, may also be the individual being tested. Such anarrangement requires owner-operators who are abusing controlled substances to removethemselves from driving if they test positive for such substances. It seems highly unlikelythat those owner-operators who are not complying with the regulations regarding the useof controlled substances will comply with other sections of the drug testing regulations.
Therefore, the Safety Board concludes that the current Federal drug testing regulationscannot adequately identify owner-operators who abuse controlled substances. A database that records positive drug and alcohol test results and refusal determinations for all commercial drivers would provide an effective way for bothemployers and certifying authorities to verify and evaluate the drug test history of allcommercial drivers. Such a database would allow employers to make more informedhiring decisions and would allow certifying authorities to determine whether a driver has apotentially disqualifying medical condition regarding substance abuse. Therefore, theSafety Board believes that the FMCSA should develop a system that records all positivedrug and alcohol test results and refusal determinations that are conducted under the DOTtesting requirements, require prospective employers to query the system before making ahiring decision, and require certifying authorities to query the system before making acertification decision. Highway Accident Report
In the New Orleans accident, many of the passengers were thrown forward from their seating compartments and later found lying on top of other passengers near seat rowfour. In addition, EMS personnel found nine passengers and the driver lying outside thevehicle. In all, 22 passengers were fatally injured as a result of this accident. The loss ofsurvivable space was apparent for some seating positions; in others, survivable space waspresent and could have been utilized had the passenger been retained within the seatingcompartment.
Investigators determined, based upon the driver's injuries and the distance that he was thrown from the bus, that the driver was not wearing a seat belt at the time of theaccident. The driver's seat was the only belted position on the motorcoach and is the onlyposition required by Federal regulations to have a seat belt.
From its investigations of past motorcoach accidents, the Safety Board has become concerned that motorcoach passengers are not adequately protected in collisions.
Although Federal Motor Vehicle Safety Standards exist for large school buses relating topassenger seating, crash protection, and body joint strength, no similar standards apply toother types of large buses, including motorcoaches. In other words, no Federal regulationor standard requires that large buses sold or operated in the United States be equipped withactive or passive occupant protection (other than for the driver).
In September 1999, the Safety Board published a report titled Bus Crashworthiness Issues 164 that addressed these concerns and examined 36 motorcoachaccidents investigated by the Board from 1968 through 1997. Based on the investigationsand current knowledge of occupant protection systems, the Safety Board concluded thatone of the primary causes of preventable injury in motorcoach accidents involving arollover, ejection, or both is occupant motion out of the seat compartment during acollision when no intrusion occurs into the seating area. In addition, the Board concludedthat the overall injury risk to occupants in motorcoach accidents involving rollover andejection could be reduced significantly by retaining the passenger in the seatingcompartment throughout the collision.
In the bus crashworthiness report, the Safety Board issued five recommendations to improve the structure and safety of motorcoaches. The Safety Board notes that theimprovements identified in this report also apply to the New Orleans accident.
Accordingly, the Board is reiterating Safety Recommendations H-99-47 through H-99-51from the bus crashworthiness report to the National Highway Traffic SafetyAdministration (NHTSA): Highway Accident Report
In 2 years, develop performance standards for motorcoach occupantprotection systems that account for frontal impact collisions, side impactcollisions, rear impact collisions, and rollovers.
Once pertinent standards have been developed for motorcoach occupantprotection systems, require newly manufactured motorcoaches to have anoccupant crash protection system that meets the newly developedperformance standards and retains passengers, including those in childsafety restraint systems, within the seating compartment throughout theaccident sequence for all accident scenarios.
Expand your research on current advanced glazing to include itsapplicability to motorcoach occupant ejection prevention, and revisewindow glazing requirements for newly manufactured motorcoaches basedon the results of this research.
In 2 years, develop performance standards for motorcoach roof strengththat provide maximum survival space for all seating positions and that takeinto account current typical motorcoach window dimensions.
Once performance standards have been developed for motorcoach roofstrength, require newly manufactured motorcoaches to meet thosestandards.
NHTSA has responded favorably to these recommendations. With regard to H-99-47 and -48, NHTSA stated in March 2000 that it would consider whether seat beltswould be beneficial in motorcoaches. However, NHTSA also noted that since only aboutfive passengers are killed in motorcoach accidents each year, it would be inappropriate toreduce funding for other programs that have the potential to save many more lives toconcentrate on motorcoach issues. NHTSA acknowledged that the crashworthiness issuesraised by the Safety Board deserve to be analyzed and said that it would examineopportunities to share the cost of research with motorcoach manufacturers.
With regard to H-99-49, in August 2001, a NHTSA representative stated that the agency is working on testing procedures for ejection mitigation in light vehicles. Theprocedures take into account window glazing as well as advanced designs for sidecurtains/airbags. NHTSA further stated that once it has an ejection mitigation testingprocedure that works for light vehicles, the agency plans to use it as a starting point forinvestigating ejection mitigation in motorcoaches.
Highway Accident Report
With regard to H-99-50 and -51, NHTSA responded that it was unaware of recent incidents where roof crush was a predominant factor in the injuries to occupants inmotorcoaches.165 It stated that although the increased sizes of side windows may lead tomotorcoaches having fewer side support columns to support the weight of the motorcoachduring rollovers, the material and manufacturing processes have improved in the 30 yearssince the Safety Board last reported an accident in which roof strength was a factor inoccupant injuries. However, contingent upon the availability of resources, NHTSA statedthat it will begin assessing the possibility of requiring motorcoaches to meet the same orsimilar standards for roof crush as do large school buses.
In April 2001, the Safety Board acknowledged that NHTSA had initiated a research plan to address Safety Recommendations H-99-47 through -51. Accordingly,pending an update on NHTSA's activities in this area, the Safety Board has classifiedSafety Recommendations H-99-47 through –51 as "Open—Acceptable Response." During the accident sequence, the motorcoach struck the terminal end of a guardrail and fractured 11 wooden guardrail posts. The 27-inch-high guardrail at theaccident scene was not designed to redirect vehicles as tall (center of gravity 39 inchesabove the ground) and heavy as a 35,250-pound motorcoach. Given an estimated speed of60 mph and the approach angle of the motorcoach, it struck the guardrail with a force thatwas 62 times more than the guardrail was designed to absorb. If the guardrail had notfailed, it may have caused the motorcoach to roll over166 because of the motorcoach'shaving a higher center of gravity than the vehicles for which the guardrail was designed. Arollover may have led to side window ejections and roof crush that would have reducedthe amount of survivable space in the bus. Although it is difficult to speculate on theextent of occupant injuries had the Custom motorcoach rolled over, the Safety Board hasdocumented the risk to occupants of bus rollovers and roof crush in its specialinvestigation report on bus crashworthiness issues.167 Although the presence of the guardrail system had little effect on the severity of the accident, Safety Board investigators were concerned that the extensive termite damagefound in some of the guardrail posts could have compromised the safety of the smallerprivate passenger vehicles that the barrier system was designed to stop.168 According to theUSFS report, the original shear strength of the undecayed portions of the posts was above 165 The Safety Board's investigation into a December 1998 motorcoach accident in Old Bridge, New Jersey (docket number HWY99MH007), revealed that one passenger, who was alive after the accident, dieddue to asphyxiation from roof crush. In addition, the Safety Board is investigating another motorcoach accident, which occurred in Canon City, Colorado, in December 1999, that resulted in extensive roof crush.
166 NTSB/SIR-99/04.
167 NTSB/SIR-99/04.
168 This type of guardrail system is designed to redirect safely small and large passenger cars. It was performance tested with vehicles that weighed between 1,764 and 4,409 pounds.
Highway Accident Report
average. However, two of the four decayed samples were determined to have considerableinsect damage, with clear indications of feeding galleries, excrement, and soil. These postshad suffered such severe attack from insects that their ability to resist impact loads wasreduced, which suggests that the posts may have failed if hit by a passenger car.
The Safety Board concludes that although it is highly unlikely that the breakaway cable terminal and W-beam guardrail system would have redirected the bus, even had theposts been in good condition, the damaged and weakened condition of the posts before theaccident makes it likely that they would have been inadequate at redirecting privatepassenger vehicles as well. The DOTD was apparently unaware of the insect damage because it does not have a program to periodically inspect guardrail posts for structural integrity. Therefore, theSafety Board believes that the DOTD should inspect all wooden guardrail posts forstructural integrity and replace those that do not meet the AASHTO crash performancedesign criteria.
The AASHTO guidelines state that preservative-treated wooden posts, such as the ones used at the accident site, require almost no maintenance, except for an occasional
cleaning and painting. However, evidence gathered from the accident site indicates that
periodic inspections of wooden guardrail posts may be warranted. Therefore, the Safety
Board believes that AASHTO should inform its members about the weakened guardrail
conditions due to termite infestation found in this accident and urge them to perform
periodic structural inspections of wooden guardrail posts.
Highway Accident Report
1. The mechanical condition of the bus, the weather, emergency management, and motor carrier management did not contribute to or influence the severity of the accident.
2. The failure of the medical certification process to remove unfit drivers is a systemic, not an isolated, problem.
3. Individuals who are authorized to perform medical examinations and certify commercial drivers as fit to drive may lack knowledge and information critical tocertification decisions. Consequently, drivers with serious medical conditions maynot be evaluated sufficiently to determine whether their condition poses a risk tohighway safety.
4. The regulations on the medical certification of commercial drivers do not reflect current medical knowledge and information and can be ambiguous regarding theconditions that may constitute disqualification.
5. The new medical certification form for commercial drivers is a substantial improvement over the previous version and, if used in its entirety and in conjunctionwith attached instructions, will aid examiners in making certification decisions.
6. Not all individuals who are authorized to perform medical examinations and certify commercial drivers as fit to drive are made aware of information sources that couldassist them with certification decisions.
7. The absence of a process under which every driver medical examination form is reviewed greatly increases the likelihood that medical certificates will be issuedinappropriately, thereby allowing medically unqualified commercial vehicle driversto continue driving.
8. In the absence of a mechanism to track all medical certification examinations, a commercial driver with a serious medical condition who is denied a medicalcertificate by one examiner may be able to obtain a medical certificate from anotherexaminer, thus subverting the purpose of the medical certification process.
9. Many drivers whose occupations and serious medical conditions are known to their employers, health care providers, and others are never reported, thereby potentiallyendangering the drivers themselves and others.
Highway Accident Report
10. Enforcement authorities cannot, in most instances, determine the validity of a medical certificate during safety inspections and routine stops because of the absence ofprocedures or information sources to validate the medical certificate itself.
11. The inability to authenticate the information on a medical certificate hampers enforcement authorities in their ability to identify unfit drivers and place them out ofservice.
12. Results of tests for controlled substances performed under the U.S. Department of Transportation testing guidelines, even when positive, are often not available toprospective employers, making it difficult for them to make well-informed hiringdecisions.
13. The current Federal drug testing regulations cannot adequately identify owner-operators who abuse controlled substances.
14. Although it is highly unlikely that the breakaway cable terminal and W-beam guardrail system would have redirected the bus, even had the posts been in goodcondition, the damaged and weakened condition of the posts before the accidentmakes it likely that they would have been inadequate at redirecting private passengervehicles as well.
The National Transportation Safety Board determines that the probable cause of this accident was the driver's incapacitation due to his severe medical conditions and thefailure of the medical certification process to detect and remove the driver from service.
Other factors that may have had a role in the accident were the driver's fatigue and thedriver's use of marijuana and a sedating antihistamine.
Highway Accident Report
To the Federal Motor Carrier Safety Administration:
Develop a comprehensive medical oversight program for interstate commercial drivers that contains the following program elements: Individuals performing medical examinations for drivers are qualified to do soand are educated about occupational issues for drivers. (H-01-17) A tracking mechanism is established that ensures that every prior applicationby an individual for medical certification is recorded and reviewed. (H-01-18) Medical certification regulations are updated periodically to permit trainedexaminers to clearly determine whether drivers with common medicalconditions should be issued a medical certificate. (H-01-19) Individuals performing examinations have specific guidance and a readilyidentifiable source of information for questions on such examinations.
(H-01-20) The review process prevents, or identifies and corrects, the inappropriateissuance of medical certification. (H-01-21) Enforcement authorities can identify invalid medical certification during safetyinspections and routine stops. (H-01-22) Enforcement authorities can prevent an uncertified driver from driving until anappropriate medical examination takes place. (H-01-23) Mechanisms for reporting medical conditions to the medical certification andreviewing authority and for evaluating these conditions between medicalcertification exams are in place; individuals, health care providers, andemployers are aware of these mechanisms. (H-01-24) Develop a system that records all positive drug and alcohol test results and refusal determinations that are conducted under the U.S. Department of Transportation testingrequirements, require prospective employers to query the system before making a hiringdecision, and require certifying authorities to query the system before making acertification decision. (H-01-25) Highway Accident Report
To the American Association of Motor Vehicle Administrators:
Urge your member States to develop a comprehensive medical oversight program for intrastate commercial drivers that contains the following program elements: Individuals performing medical examinations for drivers are qualified to do soand are educated about occupational issues for drivers.
A tracking mechanism is established that ensures that every prior applicationby an individual for medical certification is recorded and reviewed.
Medical certification regulations are updated periodically to permit trainedexaminers to clearly determine whether drivers with common medicalconditions should be issued a medical certificate.
Individuals performing examinations have specific guidance and a readilyidentifiable source of information for questions on such examinations.
The review process prevents, or identifies and corrects, the inappropriateissuance of medical certification.
Enforcement authorities can identify invalid medical certification during safetyinspections and routine stops.
Enforcement authorities can prevent an uncertified driver from driving until anappropriate medical examination takes place.
Mechanisms for reporting medical conditions to the medical certification andreviewing authority and for evaluating these conditions between medicalcertification exams are in place; individuals, health care providers, andemployers are aware of these mechanisms. (H-01-26) To the National Conference of State Legislatures:
Inform State legislatures about this accident and make them aware of the importance of establishing immunity laws for the good-faith reporting of potentiallyimpaired commercial drivers by all individuals and of ensuring that the medicalcommunity and the commercial transportation industry are familiar with these laws.
(H-01-27) To the American Association of State Highway and Transportation Officials:
Inform your members about the weakened guardrail conditions due to termite infestation found in this accident and urge them to perform periodic structural inspectionsof wooden guardrail posts. (H-01-28) Highway Accident Report
To the State of Louisiana Department of Transportation and Development:
Inspect all wooden guardrail posts for structural integrity and replace those that do not meet the American Association of State Highway and Transportation Officials crashperformance design criteria. (H-01-29) The NTSB also reiterates the following recommendations: To the National Highway Traffic Safety Administration:
In 2 years, develop performance standards for motorcoach occupantprotection systems that account for frontal impact collisions, side impactcollisions, rear impact collisions, and rollovers. (H-99-47) Once pertinent standards have been developed for motorcoach occupantprotection systems, require newly manufactured motorcoaches to have anoccupant crash protection system that meets the newly developedperformance standards and retains passengers, including those in childsafety restraint systems, within the seating compartment throughout theaccident sequence for all accident scenarios. (H-99-48) Expand your research on current advanced glazing to include itsapplicability to motorcoach occupant ejection prevention, and revisewindow glazing requirements for newly manufactured motorcoaches basedon the results of this research. (H-99-49) In 2 years, develop performance standards for motorcoach roof strengththat provide maximum survival space for all seating positions and that takeinto account current typical motorcoach window dimensions. (H-99-50) Once performance standards have been developed for motorcoach roofstrength, require newly manufactured motorcoaches to meet thosestandards. (H-99-51) Highway Accident Report
BY THE NATIONAL TRANSPORTATION SAFETY BOARD
CAROL J. CARMODY
JOHN A. HAMMERSCHMIDT
JOHN J. GOGLIA
Member
GEORGE W. BLACK, JR.
Member
Adopted: August 28, 2001
Highway Accident Report
Appendix A
Investigation and Public Hearing
The National Transportation Safety Board was notified of the New Orleans, Louisiana, accident about 1:00 p.m. on May 9, 1999. The Safety Board dispatched aninvestigative team with members from the Washington, D.C.; Atlanta, Georgia;Parsippany, New Jersey; Arlington, Texas; Denver, Colorado; and Gardena, California,offices. Groups were established to investigate highway, vehicle, and survival factors;human performance; and motor carrier operations.
Parties to the on-scene investigation were the Federal Motor Carrier Safety Administration; Louisiana Department of Transportation; Louisiana State Police; NewOrleans Police Department; United Motorcoach Association; Custom Bus Charters,Incorporated; National Seating Company; Motor Coach Industries; and TRW, CommercialSteering Systems.
The Safety Board also conducted a public hearing for this accident on January 20 and 21, 2000, in New Orleans, Louisiana. Parties to the hearing were the U.S. Departmentof Transportation; American Automobile Association; American Association of StateHighway and Transportation Officials; Commercial Vehicle Safety Alliance; NationalAssociation of Governors' Highway Safety Representatives; American TruckingAssociations, Inc.; National Private Truck Council; Owner-Operator Independent DriversAssociation, Inc.; American Bus Association; United Motorcoach Association; MotorCoach Industries; Amalgamated Transit Union; International Brotherhood of Teamsters;Transport Workers Union of America; Advocates for Highway and Auto Safety; andParents Against Tired Truckers.
Highway Accident Report
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ecords obt bpo enter of harity H ecords obt bpo enter of ecords obt bpo enter of ecords obt bpo enter of [shortness an ns n admissio vi cating "hig icate th cial Info ave a 2-year history of medi dicates "Presented n 17%." Home me . Lab ally estimated ej e had in a l insuf mi paroxysmal noncturna on was listed as ssi on-compl ency t he "report mily history mi d 3+ p ailure" and "rena (drives bus)." Commen to ast month or so." a … MUGA scan 3/98 eje en) of 34, serum creatini revepo ysp ase prog rtne f the feet) systolic function ap pril) 10 mg per day al ede od pressure an ths," and that he "had no as Lasix (furosemid mission record dge p obal Admitted an hi mon en in ad Echo fraction of 10%." See be that he "has bee eva card clo T 3/16 of breath at nigh di listed in ad we "gl Appendix B
New Orleans Driver
Appendix B
Highway Accident Report
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ecords obt bpo ffe ecords obt bpo ffe ecords obt bpo ffe ecords obt bpo ffe ecords obt estbank Primar R su Je (Marrero, Louisiana).
t must co ng that ." Progress notes nt is on dication history o e), metroprol u currently use any …di n was noted to be 89.1 kg. t for fraction is estimated to be on the dicatio onitrate) 60 mg per day y, and te u in your immed u ever or d ol) 25 mg per day ication." Pati s e on a bus tri ght on admissio 's Certificate is an t with iatrog He ath t." Disch r (metoprol nd Bumex (bumet llo nce his discha a hy h of activity as "some of e " is marked, cati dicates "tra fai ue to rena ol) 25 mg tw able s level netic posterior an ." gestive he r di rcial Driv cardio ssi tinues ), Couma iagn rge medica lazin dicate "… lure. es – Con es – er eart ide). Urine al llow up " as "charter bus driver pation eart probl he records no mission in Di di in three (warfarin twice a ove Admitted to hospi thera we T ad Echo is very dif ord Outp Ce dysp con "Occu wi wi recrea bl Underwent exam "No," i an Bumex (bumet med in Appendix B
Highway Accident Report
ed un Ochsner ons.
ecords obt bpo ffe ecords obt bpo ffe ecords obt bpo ffe ecords obt bpo ffe m immedi st (eleva pathy/mitral admit." Dischar iver)." Me , and Bu !! Referred hi normal lure," "cardio sio cathet ntly (charter bu 25 mg twice a ot a dicated e 80 nges n of in (warfarin) 5 mg per day derate aortic regurg ere noted to be aroxo gressive shortness of n (warfarin) 5 mg sions of "marke "mi patient – never returns our calls." primary care physici primary care physici primary care physici sease – beg re cian.
notes and rte t af ortness of brea lol 5 tie erate hypokin erate s "told he mage .7 y, Cou "Patient Information Form indicates: " some metopro 2.5 mg fo Primary care physicia Re crea Inp a catheter an sche Inp ou "en med pri Appendix B
Highway Accident Report
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ecords obt bpo ffe ecords obt bpo ffe ecords obt bpo ffe ecords obt bpo ffe ecords obt bpo ffe ." "Primary eart ed by primary .m. T ation" as "Driver d "C tions on admissio e with near comple Prescrip ferson Ho ." Examin rs or ga hospi work. Minor cramp %," "evid l enla t ven n on intraven n – smal severely dilated in both rhythm n dialysis, eed rm shu lar rate and pproxi rately severe bi les his work aroun nd "Other cond indica ssment indicates " ' – driver – 2 ye h mg every other day rig nd right subcla ndo epartment for "coug dialysis indicates " d dicates: "May return to work lar ultrasoun r, ri agn physici ow T dial tient echocardiogram Primary care On di no no de care T Di pre 111.4 kg.
Outp "Emplo "His empl Appendix B
Highway Accident Report
ecords obt bpo ffe ecords obt bpo f Lo ecords obt bpo ffe ) … No work. Re esia note in atient wi ced." A Qui ays, then 5 mg per day sea with shortness of eart a ogist … S arted. He has bee 3 to 4 hours.
ned by primary care physici rt att ation y notes ctitio pneu intment with ca Notes and farin) 10 dicates "h ted und tp re V in (warfarin) 5 mg risk of rk or other activities — lysis notes "O sche w? – much worse now than ht arm, ‘ h ing af morn utes … Heart aire fro to es" no er fo cial services – no f wo the work or other activities — to get worse — Nutrition Assessmen l noted as 7.2.
ealth survey performed by dia you ealth li ast ficulty performing mp limited in the kind mp t do work or other activities ng th Inp wi tachycardi Primary care physicia ho F rel symptoms we wo to cardio Outp 1/21 recrea hi di pre Sho "How "Doe "Duri cut down acco we ha acco di "Duri "I Pot Admitted to twice a da "po in pl Appendix B
Highway Accident Report
ecords obt bpo ffe ecords obt bpo ffe ecords obt bpo ffe ecords obt bpo ffe alysis blo ight no pr r transp oted as 106 e last ol 50 mg each morni informed . Patient is ight n nd metoprol 07.5" kg1 50/90. Post-dial as: sittin kg.
dicates "margin ranspl ng a new estimated ce al worker will icate esti s: sitting – d pressures noted surg alysis notes ind loo acement of Qu [4/3/99] t referral form ation T transpl eva Post-dia Post-dialysis weight Di assist p returns to dial Appendix B
Highway Accident Report
ed un Marrero Cen ecords obt bpo ffe ecords obt bpo ffe ecords obt bpo ffe ecords obt bpo ffe ecords obt bpo ffe ecords obt bpo ffe ecords obt bpo ffe , left anterio ." Con 0.1 kg t shortness of dly dil in coron scri esio catheter in lef st Qu tricl an of 23"; sides 3 times per ntricular dysfunction d right corona ft ve treatment with in treatment with in treatment with in sio catheter place note st -assess estimated nous e to return to work. Be ) of Dobu x artery th marked orker provide ng abl ed/Fri tmen d." Pre-di . Post-dial ote indi atient refuses any interven ithout escort, den catheterizatio % to 20 , lef lar surgery consul ve st 5 obutrex last week had s po nt is fru times per wee proximatel scendi rma alysis notes ind ns st 0/80, te rte gnosi Admitted Ne treatment Saturda an Patie Di sig 14 no S pro Appendix B
Highway Accident Report
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ecords obt bpo ffe ecords obt bpo ffe ecords obt bpo ffe d as: sitting f dia ences incl as 2:55 p ssu for his dry weig d ved 1 liter intraveno oted as 98.7 kg. ssible lysis ind alysis b ent had recei wa eves ‘they to lysis weig lysis pul ent beli od pressu to the emerg s notes st nutes. arrival. Pati t in an'ci 5 mi o ch 0/p nt says the nep treatment with in treatment with in is h is symptoms to ss ea d pressure of f the icated as ing alysis notes ind ssu .4 alysis notes ind ssu .5 alysis notes ind d is a alysis 12 dicated Emerge wi ep Med time of use di Di Highway Accident Report
Appendix C
Federal Motor Carrier Safety Ratings Procedures
The Motor Carrier Safety Act of 1984 directed the U.S. Secretary of Transportation to establish a procedure to determine the safety fitness of owners andoperators of commercial motor vehicles operating in interstate or foreign commerce.
Subsequently, the Federal Highway Administration set safety fitness standards andestablished a methodology for determining whether a carrier has adequate safetymanagement controls to ensure acceptable compliance with the safety requirements. Theoriginal methodology was modified as a result of the Motor Carrier Safety Act of 1990and a 1997 rulemaking. Six factors (see table C-1) form the basis for a carrier's safetyrating, that is, the degree to which a carrier is in compliance with the Federal MotorCarrier Safety Regulations and therefore meets the safety fitness standards.
Table 4. Motor carrier safety rating factors (49 CFR 385, appendix B).
Parts 387 and 390 Parts 382, 383, and 391 Parts 392 and 395 Parts 393 and 396 5 - Hazardous Materials Parts 397, 171, 177, and 180 6 - Accident Factor Recordable Preventable Rate *All factors are given equal weight.
The six factors in the rating system shown in table C-1 represent the six major categories of a motor carrier's operations covered by Federal regulations. The FederalMotor Carrier Safety Administration (FMCSA) has determined that certain sections of thereferenced Federal Motor Carrier Safety Regulation Parts are more indicative of a safemotor carrier operation than others. These selected sections are classified "acute" or"critical" (see 49 Code of Federal Regulations [CFR] 385, appendix B, section VII).
Sections classified acute define conditions that demand immediate corrective actionregardless of the overall safety posture of the motor carrier, for example, requiring orpermitting the operation of a vehicle declared out of service before repairs are made (49CFR 396.9[c][2]). Sections classified critical define conditions that indicate breakdownsin a carrier's management controls, for example, requiring or permitting a driver to driveafter having been on duty for 15 hours (49 CFR 395.3[a][2]).
Appendix C
Highway Accident Report
During an FMCSA compliance review, the carrier is evaluated on its compliance with each of the referenced Parts. A carrier that violates an acute section is assessed 1point for that factor. A carrier that violates a critical section two or more times, with thenumber of violations exceeding 10 percent of the sample reviewed (termed a "pattern ofviolations"), is assessed 1 point for that factor.
An exception to the above point assessment takes effect if the carrier's accident rate (per million miles traveled) over the previous 12 months is greater than 1.7 for acarrier operating in an urban area (entirely within 100 air miles of the home terminal) orgreater than 1.5 for all other carriers. In such cases, carriers are assessed 2 points.
Ratings for individual factors are based on the number of points assessed for that After all factors are rated, an overall rating for the carrier is determined by assembling the ratings assigned to each factor as shown in table C-2.
Table 5. Motor carrier safety rating table.
Number of unsatisfactory
Number of conditional ratings
Appendix C
Highway Accident Report
1. A carrier receiving no unsatisfactory factor ratings and 1 conditional factor rating would receive an overall rating of satisfactory.
2. A carrier receiving 1 unsatisfactory factor rating and 1 conditional factor rating would receive an overall rating of conditional.
3. A carrier receiving 2 unsatisfactory factor ratings would receive an overall rating of unsatisfactory.
Under 49 CFR 385.13, a carrier that receives an overall unsatisfactory rating is deemed "unfit" and has 60 days to correct the deficiencies found in the compliance reviewor to file an appeal with the FMCSA. A passenger carrier or a carrier transportinghazardous materials that receives an overall unsatisfactory rating has 45 days to correctthe deficiencies found in the compliance review or to file an appeal with the FMCSA. If anappeal is not filed and the carrier does not correct the deficiencies noted in the compliancereview, the carrier is deemed unfit and prohibited from continued operation.
Highway Accident Report
Appendix D
State Medical Certification Process
All 50 States and the District of Columbia have substantially adopted the Federal Motor Carrier Safety Regulations for intrastate operations, including the commercialdriver physical fitness regulations contained in 49 Code of Federal Regulations 391.
Several States have exempted agricultural and Government transportation operations fromcertain aspects of these requirements. Several States have grandfathered intrastatecommercial drivers who do not meet the Federal physical fitness requirements but haveoperated commercial vehicles before the State's adoption of these requirements.
Furthermore, a number of States have also adopted stricter rules for drivers of hazardousmaterials, school buses, and commercial passenger vehicles.
Appendix D
Highway Accident Report
ommercial L required for ha L wal le s)
and Canadian CD ne cyc ear
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in ateSt

te
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of Automotive Medic cement ashington, te of Medical Review Practices and Pr ate medical
from interviews Intrast emp
Li di cardiovascular Li ep cardiovascular Li ep cardiovascular icensing Pr Appendix D
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tion not ble to t drive CDL drivers
form a ical certificate form a ical certificate rmation 2
L medical certicate Medical certificate form a ical certificate ical certificate Li di cardiovascular Li di cardiovascular Li ep cardiovascular Intrast o mil fitness requ District of Co
Appendix D
Highway Accident Report
W than limb may al Long includ for drivers of passeng co 2 ye ewa cle rs)
CDL drivers
Medical certificate Medical certificate Medical certificate Medical certificate Non-CDL driver 0,001
Li d cardiovascular Li d cardiovascular Li e cardiovascular Li d cardiovascular Appendix D
Highway Accident Report
Me re for schoo drivers only No requi for medic ce re L ewa cle rs)
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Highway Accident Report
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Limb, vi diab cardiov Limb, vi diab cardiov Highway Accident Report
Appendix E
Instructions for Performing and Recording Physical
Examinations167

The medical examiner must be familiar with 49 CFR 391.41, Physical qualifications for drivers, and should review these instructions before performing thephysical examination. Answer each question "yes" or "no" and record numerical readingswhere indicated on the physical examination form.
The medical examiner must be aware of the rigorous physical, mental, and emotional demands placed on the driver of a commercial motor vehicle. In the interest ofpublic safety, the medical examiner is required to certify that the driver does not have anyphysical, mental, or organic condition that might affect the driver's ability to operate acommercial motor vehicle safely.
General information. The purpose of this history and physical examination is to detect the presence of physical, mental, or organic conditions of such a character andextent as to affect the driver's ability to operate a commercial motor vehicle safely. Theexamination should be conducted carefully and should at least include all of theinformation requested in the following form. History of certain conditions may be causefor rejection. Indicate the need for further testing and/or require evaluation by a specialist.
Conditions may be recorded which do not, because of their character or degree, indicatethat certification of physical fitness should be denied. However, these conditions shouldbe discussed with the driver and he/she should be advised to take the necessary steps toinsure correction, particularly of those conditions, which if neglected, might affect thedriver's ability to drive safely.
General appearance and development. Note marked overweight. Note any postural defect, perceptible limp, tremor, or other conditions that might be caused byalcoholism, thyroid intoxication or other illnesses.
Head-eyes. When other than the Snellen chart is used, the results of such test must be expressed in values comparable to the standard Snellen test. If the driver wearscorrective lenses for driving, these should be worn while driver's visual acuity is beingtested. If contact lenses are worn, there should be sufficient evidence of good tolerance ofand adaptation to their use. Indicate the driver's need to wear corrective lenses to meet thevision standard on the Medical Examiner's Certificate by checking the box, "Qualifiedonly when wearing corrective lenses." In recording distance vision use 20 feet as normal.
Report all vision as a fraction with 20 as the numerator and the smallest type read at 20 167 Extracted from 49 CFR 391.43(f).
Appendix E
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feet as the denominator. Monocular drivers are not qualified to operate commercial motorvehicles in interstate commerce.
Ears. Note evidence of any ear disease, symptoms of aural vertigo, or Meniere's Syndrome. When recording hearing, record distance from patient at which a forcedwhispered voice can first be heard. For the whispered voice test, the individual should bestationed at least 5 feet from the examiner with the ear being tested turned toward theexaminer. The other ear is covered. Using the breath which remains after a normalexpiration, the examiner whispers words or random numbers such as 66, 18, 23, etc. Theexaminer should not use only sibilants (s-sounding test materials). The opposite ear shouldbe tested in the same manner. If the individual fails the whispered voice test, theaudiometric test should be administered. For the audiometric test, record decibel loss at500 Hz, 1,000 Hz, and 2,000 Hz. Average the decibel loss at 500 Hz, 1,000 Hz and 2,000Hz and record as described on the form. If the individual fails the audiometric test and thewhispered voice test has not been administered, the whispered voice test should beperformed to determine if the standard applicable to that test can be met.
Throat. Note any irremediable deformities likely to interfere with breathing or Heart. Note murmurs and arrhythmias, and any history of an enlarged heart, congestive heart failure, or cardiovascular disease that is accompanied by syncope,dyspnea, or collapse. Indicate onset date, diagnosis, medication, and any currentlimitation. An electrocardiogram is required when findings so indicate.
Blood pressure (BP). If a driver has hypertension and/or is being medicated for hypertension, he or she should be recertified more frequently. An individual diagnosedwith mild hypertension (initial BP is greater than 160/90 but below 181/105) should becertified for one 3-month period and should be recertified on an annual basis thereafter ifhis or her BP is reduced. An individual diagnosed with moderate to severe hypertension(initial BP is greater than 180/104) should not be certified until the BP has been reduced tothe mild range (below 181/105). At that time, a 3-month certification can be issued. Oncethe driver has reduced his or her BP to below 161/91, he or she should be recertified every6 months thereafter.
Lungs. Note abnormal chest wall expansion, respiratory rate, breath sounds including wheezes or alveolar rales, impaired respiratory function, dyspnea, or cyanosis.
Abnormal finds on physical exam may require further testing such as pulmonary testsand/or x-ray of chest.
Abdomen and viscera. Note enlarged liver, enlarged spleen, abnormal masses, bruits, hernia, and significant abdominal wall muscle weakness and tenderness. If thediagnosis suggests that the condition might interfere with the control and safe operation ofa commercial motor vehicle, further testing and evaluation is required.
Genital-urinary and rectal examination. A urinalysis is required. Protein, blood or sugar in the urine may be an indication for further testing to rule out any underlying Appendix E
Highway Accident Report
medical problems. Note hernias. A condition causing discomfort should be evaluated todetermine the extent to which the condition might interfere with the control and safeoperation of a commercial motor vehicle.
Neurological. Note impaired equilibrium, coordination, or speech pattern; paresthesia; asymmetric deep tendon reflexes; sensory or positional abnormalities;abnormal patellar and Babinski's reflexes; ataxia. Abnormal neurological responses maybe an indication for further testing to rule out an underlying medical condition. Anyneurological condition should be evaluated for the nature and severity of the condition, thedegree of limitation present, the likelihood of progressive limitation, and the potential forsudden incapacitation. In instances where the medical examiner has determined that morefrequent monitoring of a condition is appropriate, a certificate for a shorter period shouldbe issued.
Spine, musculoskeletal. Previous surgery, deformities, limitation of motion, and tenderness should be noted. Findings may indicate additional testing and evaluationshould be conducted.
Extremities. Carefully examine upper and lower extremities and note any loss or impairment of leg, foot, toe, arm, hand, or finger. Note any deformities, atrophy, paralysis,partial paralysis, clubbing, edema, or hypotonia. If a hand or finger deformity exists,determine whether prehension and power grasp are sufficient to enable the driver tomaintain steering wheel grip and to control other vehicle equipment during routine andemergency driving operations. If a foot or leg deformity exists, determine whethersufficient mobility and strength exist to enable the driver to operate pedals properly. In thecase of any loss or impairment to an extremity which may interfere with the driver'sability to operate a commercial motor vehicle safely, the medical examiner should state onthe medical certificate "medically unqualified unless accompanied by a Skill PerformanceEvaluation Certificate." The driver must then apply to the Field Service Center of theFMCSA, for the State in which the driver has legal residence, for a Skill PerformanceEvaluation Certificate under Sec. 391.49.
Laboratory and other testing. Other test(s) may be indicated based upon the medical history or findings of the physical examination.
Diabetes. If insulin is necessary to control a diabetic driver's condition, the driver is not qualified to operate a commercial motor vehicle in interstate commerce. If milddiabetes is present and it is controlled by use of an oral hypoglycemic drug and/or diet andexercise, it should not be considered disqualifying. However, the driver must remain underadequate medical supervision.
Upon completion of the examination, the medical examiner must date and sign the form, provide his/her full name, office address and telephone number. The completedmedical examination form shall be retained on file at the office of the medical examiner.
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Appendix F
Medical Advisory Criteria for Evaluation Under 49 CFR Part
391.41168

Note: Unlike regulations, which are codified and have a statutory base, the
recommendations in this advisory are simply guidance established to help the medicalexaminer determine a driver's medical qualifications pursuant to Section 391.41 of theFederal Motor Carrier Safety Regulations (FMCSRs). The Office of Motor CarrierResearch and Standards routinely sends copies of these guidelines to medical examiners toassist them in making an evaluation. The medical examiner may, but is not required to,accept the recommendations. Section 390.3(d) of the FMCSRs allows employers to havemore stringent medical requirements.
§ 391.41(b)(1) - A person is physically qualified to drive a commercial motor
vehicle if that person: Has no loss of a foot, leg, hand, or arm, or has been granted a Skill PerformanceEvaluation (SPE) Certificate pursuant to Section 391.49.
For any loss of a foot, leg, hand, or arm, a person who is otherwise qualified under the Federal Motor Carrier Safety Regulations (FMCSRs) must apply for a SkillPerformance Evaluation (SPE) certificate. The State Director will make the finaldetermination whether the defect will interfere with the driver's ability to control andsafely drive a motor vehicle.
With the advancement of technology, medical aids and equipment modifications have been developed to compensate for certain disabilities. The Skill PerformanceEvaluation (formerly the Limb Waiver Program) was designed to allow persons with theloss of a hand, foot or limb to qualify under the FMCSRs by use of prosthetic devices orequipment modifications which enable them to safely operate a commercial motorvehicle. Since there are no medical aids equivalent to the original body limb, certain risksare still present, and thus restrictions may be included on individual SPE certificates whena State Director for the FMCSA determines they are necessary to be consistent with safetyand public interest.
If the driver is found otherwise medically qualified (§ 391.41(b)(3) through (13)), the examining physician must include the statement "medically unqualified unlessaccompanied by a SPE certificate" on the medical certificate issued pursuant to§ 391.43(g).
168 Text portion of advisory reproduced on July 19, 2001, from the Web site of the Federal Motor Carrier Appendix F
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If a joint application is made, the letter of application must be submitted to the State Director in the Service Center in which the carrier's principal place of business islocated. If a unilateral SPE application is filed, the application must be submitted to theState Director in the Service Center in which the driver has legal residence. The addressesfor these service centers are found in Section 390.27 of the FMCSRs.
§ 391.41(b)(2) - A person is physically qualified to drive a commercial motor
vehicle if that person has no impairment of: i. A hand or finger which interferes with prehension or power grasping; ii. An arm, foot, or leg which interferes with the ability to perform normal tasksassociated with operating a motor vehicle; Any other significant limb defect or limitation which interferes with the ability toperform normal tasks associated with operating a motor vehicle; Has been granted a Skill Performance Evaluation (SPE) pursuant to Section391.49.
If the examining physician determines that an impairment (e.g., partial hand or finger amputation, or paralysis) in any way interferes with the driver's ability to performnormal tasks associated with operating a commercial motor vehicle, then the driverbecomes subject to the SPE certification program pursuant to Section 391.49. If the driveris found otherwise medically qualified (§ 391.41(b)(3) through (13)), the examiningphysician must include the statement "medically unqualified unless accompanied by aSPE certificate" on the medical certificate issued pursuant to § 391.43(g).
The driver and the motor carrier are subject to appropriate penalty if the driver operates a motor vehicle in interstate commerce without a current SPE certificate forhis/her physical impairment.
If a joint SPE application is filed, it must be submitted to the State Director in the service center in which the carrier's principal place of business is located. If a unilateralSPE application is filed, it must be submitted to the State Director in the service center inwhich the driver has legal residence. The addresses for these service centers are found inSection 390.27 of the Federal Motor Carrier Safety Regulations.
§ 391.41(b)(3) - A person is physically qualified to drive a commercial motor
vehicle if that person: Has no established medical history or clinical diagnosis of diabetes mellituscurrently requiring insulin for control.
Appendix F
Highway Accident Report
There is no provision in the Federal Motor Carrier Safety Regulations (FMCSRs) for an exemption from the minimum physical requirement with respect to theinsulin-using diabetic. Diabetes mellitus is a disease which, on occasion, can result in aloss of consciousness or orientation in time and space. Individuals who require insulin forcontrol have conditions which can get out of control by the use of too much or too littleinsulin, or food intake not consistent with the insulin dosage. Incapacitation may occurfrom symptoms of hyperglycemic or hypoglycemic reactions (drowsiness,semiconsciousness, diabetic coma, or insulin shock).
The administration of insulin is, within itself, a complicated process requiring insulin, syringe, needle, alcohol sponge and a sterile technique. Factors related tolong-haul commercial motor vehicle operations, such as fatigue, lack of sleep, poor diet,emotional conditions, stress, and concomitant illness, compound the diabetic problem.
Because of these inherent dangers, the FMCSA has consistently held that a diabetic whouses insulin for control does not meet the minimum physical requirements of theFMCSRs.
Hypoglycemic drugs, taken orally, are sometimes prescribed for diabetic individuals to help stimulate natural body production of insulin. If the condition can becontrolled by the use of oral medication and diet, then an individual may be qualifiedunder the present rule.
§ 391.41(b)(4) - A person is physically qualified to drive a commercial motor
vehicle if that person: Has no current clinical diagnosis of myocardial infarction, angina pectoris,coronary insufficiency, thrombosis, Any other cardiovascular disease of a variety known to be accompanied bysyncope, dyspnea, collapse, or congestive cardiac failure.
The term "has no current clinical diagnosis of" is specifically designed to encompass (1) a current cardiovascular condition; and/or (2) a cardiovascular conditionwhich has not fully stabilized regardless of the time limit. The term "known to beaccompanied by" is defined to include a diagnosis of a cardiovascular disease which is (1)accompanied by symptoms of syncope, dyspnea, collapse, or congestive cardiac failure;and/or which is (2) likely to cause syncope, dyspnea, collapse, or congestive cardiacfailure.
It is the intent of the Federal Motor Carrier Safety Regulations to render unqualified a driver who has a current cardiovascular disease which is accompanied byand/or likely to cause symptoms of syncope, dyspnea, collapse, or congestive cardiacfailure. The subjective decision of whether the nature and severity of an individual'scondition will likely cause symptoms of cardiovascular insufficiency is on an individualbasis and qualification rests with the medical examiner and the motor carrier. In thosecases where there is an occurrence of cardiovascular insufficiency (myocardial infarction, Appendix F
Highway Accident Report
thrombosis, etc.), it is suggested that, before a driver is certified, he/she have a normalresting and stress EKG, no residual complications, no physical limitations, and is taking nomedication likely to interfere with safe driving.
Coronary artery bypass surgery and pacemaker implantation are remedial procedures and thus not necessarily unqualifying. However, the final determination mustbe based on functional assessment. A pacemaker recipient should be followed by a centerspecializing in this field.
Coumadin is a medical treatment which can improve the health and safety of the driver and should not, by its use, medically disqualify the commercial driver.
§ 391.41(b)(5) - A person is physically qualified to drive a commercial motor
vehicle if that person: Has no established medical history or clinical diagnosis of a respiratorydysfunction likely to interfere with his/her ability to control and drive acommercial motor vehicle safely.
To function adequately the cells of the body require a continuous supply of oxygen and removal of carbon dioxide. Proper functioning of the respiratory system ensures thisadequate gaseous exchange. Any interruption in respiration for more than a few minuteswill result in irreversible brain damage and, ultimately death.
Since a driver must be alert at all times, any change in his or her mental state is in direct conflict with highway safety. Even the slightest impairment in respiratory functionunder emergency conditions (when greater oxygen supply is necessary for performance)may be detrimental to safe driving.
There are many conditions that interfere with oxygen exchange and may result in incapacitation, including emphysema, chronic asthma, carcinoma, tuberculosis, chronicbronchitis and sleep apnea. If the medical examiner detects a respiratory dysfunction, thatin any way is likely to interfere with the driver's ability to safely control and drive a motorvehicle, the driver must be referred to a specialist for further evaluation and therapy. Oncethe driver meets the minimum physical requirements of the Federal Motor Carrier SafetyRegulations, a certificate can be issued.
Anticoagulation therapy for deep vein thrombosis and/or pulmonary thromboembolism is not unqualifying once optimum dose is achieved, provided lowerextremity venous examinations remain normal and the treating physician gives a favorablerecommendation.
§ 391.41(b)(6) - A person is physically qualified to drive a commercial motor
vehicle if that person: Has no current clinical diagnosis of high blood pressure likely to interfere withhis/her ability to operate a commercial motor vehicle safely.
Appendix F
Highway Accident Report
Hypertension alone is unlikely to cause sudden collapse; however, the likelihood increases when target organ damage, particularly cerebral vascular disease, is present.
This regulatory criteria is based on FMCSA's Cardiac Conference recommendations,which used the report of the 1984 Joint National Committee on Detection, Evaluation, andTreatment of High Blood Pressure.
Mild Hypertension is considered an initial BP of 161-180 systolic and/or 91-104
1. The driver is given a 3-month period to reduce the BP to less than or equal to160/90; the medical examiner should state on the medical certificate that it is onlyvalid for that 3-month period.
2. If at any time during or by the end of this 3-month period the BP is found to beless than or equal to 160/90, a medical certificate may be issued for a 1-yearperiod. However, the BP must confirm blood pressure control in the third monthof this 1-year period.
3. The individual must be certified annually thereafter.
Moderate to Severe Hypertension is considered an initial BP of greater than 180
systolic and/or greater than 104 diastolic.
1. The driver should not be qualified, even temporarily, until the BP has beenreduced to less than 181/105.
2. Once the individual's BP is below 181 and/or 105, the driver may be issued one3-month certificate. During this 3-month period, the BP must be reduced to lessthan or equal to 160/90.
3. If at any time during or by the end of this 3-month period the BP is found to beless than or equal to 160/90, a medical certificate may be issued for a 6-monthperiod. However, the BP must be confirmed in the third month of this 6-monthperiod.
4. For initial BP greater than 180 and/or 104, documentation of continued controland recertification should be made every 6 months and the expiration date statedon the medical certificate.
Commercial drivers who present for certification with a normal BP reading, but who are taking medication for hypertension should be certified on the same basis asindividuals who present with BPs in the mild to moderate range.
An elevated BP finding should be confirmed by at least two subsequent measurements on different days. Inquiry should be made regarding smoking,cardiovascular disease in relatives, and immoderate use of alcohol. An electrocardiogram(ECG) and blood profile, including glucose, cholesterol, HDL cholesterol, creatinine andpotassium, should be made. An echocardiogram and chest x-ray are desirable in subjectswith moderate or severe hypertension.
Appendix F
Highway Accident Report
Since the presence of target organ damage increases the risk of sudden collapse, group 3 or 4 hypertensive retinopathy, left ventricular hypertrophy not otherwiseexplained (echocardiography or ECG by Estes criteria), evidence of severely reduced leftventricular function, or serum creatinine of greater than 2.5 warrants the driver beingfound unqualified to operate a commercial motor vehicle in interstate commerce.
Treatment includes nonpharmacologic and pharmacologic modalities as well as counseling to reduce other risk factors. Most antihypertensive medications also have sideeffects, the importance of which must be judged on an individual basis. Side effects ofsomnolence or syncope are particularly undesirable in commercial drivers. Commercialdrivers should be informed of the side effects of drug therapy and the interaction of thesedrugs with other prescription drugs, nonprescription drugs, and alcohol.
Surgically Corrected Hypertension:
A commercial driver who has normal blood pressure 3 or more months after a successful operation for pheochromocytoma, primary aldosteronism (unless bilateraladrenalectomy has been performed), renovascular disease, or unilateral renal parenchymaldisease, and who shows no evidence of target organ damage may be qualified.
Hypertension that persists despite surgical intervention with no target organ diseaseshould be evaluated and treated following the guidelines set forth above.
§ 391.41(b)(7) - A person is physically qualified to drive a commercial motor
vehicle if that person: Has no established medical history or clinical diagnosis of a rheumatic, arthritic,orthopedic, muscular, neuromuscular or vascular disease which interferes withhis/her ability to control and operate a commercial motor vehicle safely.
Certain diseases are known to have acute episodes of transient muscle weakness, poor muscular coordination (ataxia), abnormal sensations (paresthesia), decreasedmuscular tone (hypotonia), visual disturbances and pain which may be suddenlyincapacitating. With each recurring episode, these symptoms may become morepronounced and remain for longer periods of time. Other diseases have more insidiousonsets and display symptoms of muscle wasting (atrophy), swelling and paresthesia whichmay not suddenly incapacitate a person but may restrict his/her movements and eventuallyinterfere with the ability to safely operate a motor vehicle. In many instances thesediseases are degenerative in nature or may result in deterioration of the involved area.
Once the individual has been diagnosed as having a rheumatic, arthritic, orthopedic, muscular, neuromuscular or vascular disease, then he/she has an establishedhistory of that disease. The physician, when examining an individual, should consider thefollowing: Appendix F
Highway Accident Report
1. the nature and severity of the individual's condition (such as sensory loss orloss of strength); 2. the degree of limitation present (such as range of motion); 3. the likelihood of progressive limitation (not always present initially but maymanifest itself over time); and 4. the likelihood of sudden incapacitation.
If the medical examiner determines that the disease or condition is likely to interfere with a driver's ability to safely operate a motor vehicle, the driver cannot becertified and must be sent to a specialist. In cases where more frequent monitoring isrequired, a certificate for a shorter time period may be issued.
§ 391.41(b)(8) - A person is physically qualified to drive a commercial motor
vehicle if that person: Has no established medical history or clinical diagnosis of epilepsy; any other condition which is likely to cause the loss of consciousness; or any lossof ability to control a commercial motor vehicle.
Epilepsy is a chronic functional disease characterized by seizures or episodes that occur without warning, resulting in loss of voluntary control which may lead to loss ofconsciousness and/or seizures. Therefore, the following drivers cannot be qualified: 1. a driver who has a medical history of epilepsy; or 2. a driver who has a current clinical diagnosis of epilepsy; or 3. a driver who is taking antiseizure medication.
If an individual has had a nonepileptic seizure or an episode of loss of consciousness of unknown cause which did not require antiseizure medication, thedecision as to whether that person's condition may result in the loss of consciousness orloss of ability to control a motor vehicle is made on an individual basis by the medicalexaminer in consultation with the treating physician. Before certification is considered, itis suggested that a 6-month waiting period elapse from the time of the episode. Followingthe waiting period, it is recommended that the individual have a complete neurologicalexamination. If the results of the examination are negative and antiseizure medication isnot required, then the driver may be qualified.
In those individual cases where a driver had a nonepileptic seizure or an episode of loss of consciousness that resulted from a known medical condition (e.g., drug reaction,high temperature, acute infectious disease, dehydration, or acute metabolic disturbance),certification should be deferred until the driver has fully recovered from that condition,has no existing residual complications, and is not taking antiseizure medication.
Appendix F
Highway Accident Report
§ 391.41(b)(9) - A person is physically qualified to drive a commercial motor
vehicle if that person: Has no mental, nervous, organic, or functional disease or psychiatric disorderlikely to interfere with the driver's ability to drive a commercial motor vehiclesafely.
Emotional or adjustment problems contribute directly to an individual's level of memory, reasoning, attention, and judgment. These problems often underlie physicaldisorders. A variety of functional disorders can cause drowsiness, dizziness, confusion,weakness, or paralysis that may lead to incoordination, inattention, loss of functionalcontrol and susceptibility to accidents while driving. Physical fatigue, headache, impairedcoordination, recurring physical ailments, and chronic "nagging" pain may be present tosuch a degree that certification for commercial driving is inadvisable. Somatic andpsychosomatic complaints should be thoroughly examined when determining anindividual's overall fitness to drive. Disorders of a periodically incapacitating nature, evenin the early stages of development, may warrant disqualification.
Many bus and truck drivers have documented that "nervous trouble" related to neurotic, personality, emotional or adjustment problems is responsible for a significantfraction of their preventable accidents. The degree to which an individual is able toappreciate, evaluate and adequately respond to environmental strain and emotional stressis critical when assessing an individual's mental alertness and flexibility to cope with thestresses of commercial vehicle driving.
When examining the driver, it should be kept in mind that individuals who live under chronic emotional upsets may have deeply ingrained maladaptive or erraticbehavior patterns. Excessively antagonistic, instinctive, impulsive, openly aggressive,paranoid or severely depressed behavior greatly interfere with the driver's ability to drivesafely. Those individuals who are highly susceptible to frequent states of emotionalinstability (schizophrenia, affective psychoses, paranoia, anxiety or depressive neuroses)may warrant disqualification.
Careful consideration should be given to the side effects and interactions of medications in the overall qualification determination.
§ 391.41(b)(10) - A person is physically qualified to drive a commercial motor
vehicle if that person: Appendix F
Highway Accident Report
Has a distant visual acuity of at least 20/40 (Snellen) in each eye with or withoutcorrective lenses; distant binocular acuity of at least 20/40 (Snellen) in both eyes with or withoutcorrective lenses; field of vision of at least 70 degrees in the horizontal meridian in each eye; the ability to recognize the colors of traffic signals and devices showing standardred, green, and amber.
The term "ability to recognize the colors of" is interpreted to mean if a person can recognize and distinguish among traffic control signals and devices showing standard red,green, and amber, he/she meets the minimum standard, even though he/she may havesome type of color perception deficiency. If certain color perception tests are administered(such as Ishihara, Pseudoisochromatic, Yarn, etc.), and doubtful findings are discovered, acontrolled test using signal red, green, and amber may be employed to determine thedriver's ability to recognize these colors.
Contact lenses are permissible if there is sufficient evidence to indicate that the driver has good tolerance and is well adapted to their use. Use of a contact lens in one eyefor distant visual acuity and another lens in the other eye for near vision is not acceptable,nor are telescopic lenses acceptable for driving commercial motor vehicles.
If an individual meets the criteria by the use of glasses or contact lenses, the following statement shall appear on the Medical Examiner's Certificate: "Qualified only ifwearing corrective lenses." § 391.41(b)(11) - A person is physically qualified to drive a commercial motor
vehicle if that person: First perceives a forced whispered voice in the better ear at not less than five feetwith or without the use of a hearing aid, if tested by use of an audiometric device, does not have an average hearing loss inthe better ear greater than 40 decibels at 500 Hz, 1,000 Hz and 2,000 Hz with orwithout a hearing aid when the audiometric device is calibrated to the AmericanNational Standard [formerly American Standard Association (ASA)] (Z24.5—1951).
There are two organizations that set forth frequently used audiometric calibration standards, the American National Standards Institute (ANSI, S3, 6-1969) and theInternational Standards Organization (ISO, 1964). Since the prescribed standard under the Appendix F
Highway Accident Report
Federal Motor Carrier Safety Regulations is the ANSI, it may be necessary to convert theaudiometric results: 1. at 500 Hz subtract 14 dB from the ISO reading to get the ANSI reading, 2. at 1,000 Hz subtract 10 dB from the ISO reading, and 3. at 2,000 Hz subtract 8.5 dB from the ISO reading.
The final figure is derived by averaging the readings of the three frequencies (e.g., If the loss reading at 500 Hz is 30 dB, at 1,000 Hz is 30 dB, and at 2,000 Hz is 52 dB, theaverage of the three readings is 37 dB, and the driver should be qualified).
If an individual meets the criteria by using a hearing aid, the driver must wear that hearing aid and have it in operation at all times while driving. Also, the driver must be inpossession of a spare power source for the hearing aid.
If an individual meets the criteria by the use of a hearing aid, the following statement must appear on the Medical Examiner's Certificate "Qualified only whenwearing a hearing aid." § 391.41(b)(12) - A person is physically qualified to drive a commercial motor
vehicle if that person: Does not use a controlled substance identified in 21 CFR 1308.11 Schedule I, anamphetamine, a narcotic, or any other habit-forming drug. Exception: A drivermay use such a substance or drug, if the substance or drug is prescribed by alicensed medical practitioner who is familiar with the driver's medical history andassigned duties; and has advised the driver that the prescribed substance or drugwill not adversely affect the driver's ability to safely operate a commercial motorvehicle.
This exception does not apply to the use of methadone.
The intent of the medical certification process is to medically evaluate a driver to ensure that the driver has no medical condition which interferes with the safe performanceof driving tasks on a public road. If a driver uses a Schedule I drug or other substance, anamphetamine, a narcotic, or any other habit-forming drug, it may be cause for the driver tobe found medically unqualified. Motor carriers are encouraged to obtain a practitioner'swritten statement about the effects on transportation safety of the use of a particular drug.
A test for controlled substances is not required as part of this biennial certification process. The FMCSA or the driver's employer should be contacted directly forinformation on controlled substances and alcohol testing under Part 382 of the FMCSRs.
The term "uses" is designed to encompass instances of prohibited drug use determined by a physician through established medical means. This may or may notinvolve body fluid testing. If body fluid testing takes place, positive test results should beconfirmed by a second test of greater specificity. The term "habit-forming" is intended to Appendix F
Highway Accident Report
include any drug or medication generally recognized as capable of becoming habitual, andwhich may impair the user's ability to operate a motor vehicle safely.
The driver is medically unqualified for the duration of the prohibited drug(s) use and until a second examination shows the driver is free from the prohibited drug(s) use.
Recertification may involve a substance abuse evaluation, the successful completion of adrug rehabilitation program, and a negative drug test result. Additionally, given that thecertification period is normally two years, the examiner has the option to certify for aperiod of less than two years if this examiner determines more frequent monitoring isrequired.
This is contingent on the treating/prescribing medical practitioner making a good faith judgment, with notice of the driver's assigned duties and on the basis of availablemedical history, that use of the substance by the driver at the prescribed or authorizeddosage level is consistent with the safe performance of the driver's duties. Finally, thesubstance's use must be at the dosage prescribed or authorized.
§ 391.41(b)(13) - A person is physically qualified to drive a commercial motor
vehicle if that person: Has no current clinical diagnosis of alcoholism.
The term "current clinical diagnosis" is specifically designed to encompass a current alcoholic illness or those instances where the individual's physical condition hasnot fully stabilized, regardless of the time element. If an individual shows signs of havinga possible alcohol-use problem, he or she should be referred to a specialist trained to dealin such matters. After this individual has been treated and/or undergone appropriatecounseling, he/she may be considered for certification.
Highway Accident Report
Appendix G
State Laws Regarding Unfit Commercial Drivers
Table 6. Ability of States to offer immunity to individuals reporting concerns regarding
commercial vehicle driver fitness.
Power to disqualify
Immunity to persons who in
Immunity to physicians
good faith report an unfit driver
who report an unfit
District of
Appendix G
Highway Accident Report
Power to disqualify
Immunity to persons who in
Immunity to physicians
good faith report an unfit driver
who report an unfit
New Jersey
New Mexico
North Dakota
Rhode Island
South Dakota
Source: From the Association for the Advancement of Automotive Medicine and Federal Highway Administration, Update of Medical Review Practices and Procedures in U.S. and Canadian Commercial Driver Licensing Programs, PB97-194393INZ (Springfield, Virginia: National Technical Information Service [NTIS], 1997).
Highway Accident Report
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Medical-Related Safety
Appendix H
Highway Accident Report
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Appendix I
International Commercial Vehicle Driver Certification Programs
The Safety Board conducted a brief survey of the medical certification programs of the United Kingdom, Canada, and Australia to compare them with U.S. programs.
These countries were selected mainly because the common language made informationgathering simpler. However, the striking differences between these three countries make acomparison of their programs worthwhile. Information on what is known about theMexican medical certification system is also included.
The United Kingdom
In the United Kingdom, medical fitness requirements are part of the commercial driver's license (that is, Group 2 licenses). Group 2 license holders include drivers oftrucks (category C) or buses (category D). Licenses are normally issued at age 21 and arevalid until age 45, with exceptions for armed forces and certain passenger carrying vehiclelicenses. After age 45, licenses are renewable every 5 years to age 65 unless restricted to ashorter period for medical reasons. From age 65 onward, the licenses are renewableannually. The Driver and Vehicle Licensing Agency (DVLA) does not issue licenses fortaxis, ambulances, or emergency service vehicles. However, the Medical Commission onAccident Prevention recommends that Group 2 medical standards be applied to thesecategories as an occupational health policy.
Only physicians may perform examinations for the purpose of licensure. No registry of examiners exists; drivers are allowed to choose their examiner. Examiners areonly required to perform the examination, complete the examination form (D4), andvalidate it with an individualized physician's stamp. Examiners are not responsible forcertifying the fitness of drivers and are not required to provide an opinion on that matter.
Once an examination is completed, drivers send the D4 to the DVLA. The DVLA tracksand reviews each D4 submitted and makes a fitness determination for each driver.
The D4, which can be obtained at any post office, lists the medical standards by which commercial drivers are evaluated. Physicians desiring information on theevaluation process can consult several sources of information. The DVLA provides its AtA Glance booklet, including the regulations and guidelines that apply to Group 2 licenseholders, to all health care professionals requesting it. 169 If more specific information oradvice is needed, doctors may write to the DVLA or may contact its medical advisersduring office hours. In addition, the government-sponsored Medical Commission on 169 Department of Environment, Transport and the Regions, Driver and Vehicle Licensing Agency, At a Glance (Swansea, United Kingdom: DLVA, 2000). This information is also available on the DVLA Web site Appendix I
Highway Accident Report
Accident Prevention publishes a booklet entitled, Medical Aspects of Fitness to Drive,170which offers further guidance for examiners.
Drivers are responsible for informing the DVLA of health problems that may affect their ability to operate a commercial vehicle. This notification is via an honorsystem. However, insurance companies may deny coverage to drivers who have notinformed the DVLA of a potentially disqualifying disease or injury.
State and Territorial licensing authorities carry out the administrative processes for licensing and medical certification. Although no national policy is in place for theseprocesses, national guidelines setting the minimum standards of vehicle operation andallowing for interstate commerce are voluntarily followed by the State and Territoriallicensing authorities.
Commercial drivers in Australia are only required to possess a current valid driver's license for the class of heavy vehicle they are driving. Upon application for issueor renewal of a license, drivers are required to self-certify that they do not have medicalconditions that may impair driving. Drivers are also required to report to the licensingauthority if they become aware of such a medical condition.
A driver who informs the licensing authority of a medical condition receives an examination form. These forms can vary from state to state, but most require doctors toinclude their name, address, phone number, and signature. Most driver licensingauthorities indicate (by name) which medical standards should be applied on this medicalexamination form. Additional guidelines instruct doctors unfamiliar with the medicalcriteria on how to obtain further information.171 The driver can make an appointment with a physician of his or her choice, who would conduct the examination and complete the form. Only physicians are allowed toperform examinations. An examiner registry does not exist, although it has been inconsideration for several years. The main concern about establishing a registry is that itmight severely limit or even eliminate the choice of physicians in low population areas.
Once the examination is completed, the physician returns the original form to the licensing authority and may keep a copy if so desired. As is the case in the UnitedKingdom, the licensing authority certifies a commercial driver as fit to drive. Indetermining whether to issue a license based on the examination certificate, issuingofficers often telephone the examining physician to discuss the information provided.
170 J.F. Taylor, Medical Aspects of Fitness to Drive: A Guide for Medical Practicioners (London: Medical Commission on Accident Prevention, 1995).
171 National Road Transport Commission, Medical Examination of Commercial Vehicle Drivers (Melbourne, Australia: National Road Transport Commission, 1999).
Appendix I
Highway Accident Report
Law enforcement checks are normally not done on a person's medical history; the possession of a current license would be the basis for assuming that the driver is medicallyfit.
In Canada, medical certification is part of the driver's license. As in the United Kingdom and Australia, holding a current and valid license is proof of medical fitness.
Licensing is under the exclusive jurisdiction of the Provinces and Territories. However,Canada's National Safety Code includes a section devoted to the Medical Standards forDrivers, which has been voluntarily adopted by the Provincial and Territorial licensingagencies as the minimum fitness requirement for drivers. Physicians, representing eachProvince and Territory, review the standards every 2 years to keep them current. Inaddition, the Canadian Medical Association publishes a guide to further help physicians intheir decision to qualify drivers.
Medical examinations are required every 5 years before age 45. They are required every 3 years for drivers between 45 and 65 and annually thereafter. Not filing a medicalexamination results in either a license suspension or a downgrade (to a lower vehicleclassification) of the commercial license. In addition to the periodic examinations, driversmust also complete a medical questionnaire on the back of their license renewalapplication. If a potentially disqualifying condition is indicated, further medical review istriggered, and the driver is sent a medical examination form.
Only physicians may evaluate the physical fitness of commercial drivers.
Although a national registry of physicians does not exist, most provinces do requiredrivers to visit "recognized" physicians. For example, physicians in Manitoba must beregistered with the College of Physicians and Surgeons of Manitoba.
Although physicians are asked to provide medical information and a recommendation on the fitness of the driver, the licensing agency ultimately approves ordisapproves the driver's medical information. Physicians are required by law to report tothe licensing agency conditions that may interfere with a driver's ability to safely operatea vehicle. In Manitoba, physicians are protected by legislation from liability forreporting.172 Canada does not have a waiver system; cases are reviewed individually by the provincial medical review boards. For example, diabetics are not automatically refusedlicenses but are evaluated using criteria developed by the Canadian Diabetes Association,the Medical Standards for Drivers, and the Canadian Medical Association.173 172 Shelley Serle, Assistant Supervisor, Medical Records Section, Driver and Vehicle Licensing, Manitoba Highway and Government Services, Canada, e-mail correspondence, August 25, 2000.
173 Dr. David Irving, Chairman, Manitoba Medical Review Board, testimony, National Transportation Safety Board public hearing, Highway Transportation Safety Aspects of the North American Free Trade Agreement, Los Angeles, California, October 20 through 22, 1999.
Appendix I
Highway Accident Report
Mexico's commercial driver's licensing system incorporates medical certification.
A commercial driver's license can be issued to individuals who are least 18 (or at least 21for international drivers). Commercial drivers' licenses are renewed every 2 years, atwhich time drivers are required to be medically examined. However, drivers who sufferfrom medical conditions that may affect driving performance may be examined morefrequently.
Ninety-six percent of passenger transportation in Mexico is by bus. Because of this, drivers of commercial passenger vehicles are subjected to a much stricter medicalexamination process than other commercial drivers. They are medically examined beforeevery trip by examiners located at the bus terminals. Mexico even has mobile medicaltesting, and a driver can be stopped while on duty to have the testing administered.
Only physicians are allowed to become examiners. All examiners are Federal employees and are required to attend an examiners' training program. After completing anexamination, the form examiner forwards the form to a central site, where it is input into adatabase that can be used to review and track driver fitness information. Mexico currentlydoes not have a waiver program.174 174 C.P. Alfonso Salinas Corral, Director General Adjunto de Operacion, Subsecretaria de Transporte, Mexico, interview, October 2000.
Highway Accident Report
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Guida erasmus 2007-2013:layout 1.qxd

UNIVERSITÀ degli STUDI di CASSINO Ufficio per l'internazionalizzazione Lifelong Learning Programme / ERASMUS Guida alla mobilità 1. Il programma LLP/Erasmus Il Programma d'azione comunitaria nel campo dell'apprendimento permanente, oLifelong Learning Programme (LLP), è stato istituito con decisione del Parlamentoeuropeo e del Consiglio il 15 novembre 2006. Esso riunisce, al suo interno, tutte le ini-ziative di cooperazione europea nell'ambito dell'istruzione e della formazione dal 2007al 2013.

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Eur Radiol (2012) 22:39–50DOI 10.1007/s00330-011-2260-x Non-invasive assessment of functionally relevant coronaryartery stenoses with quantitative CT perfusion: preliminaryclinical experiences Aaron So & Gerald Wisenberg & Ali Islam & Justin Amann & Walter Romano &James Brown & Dennis Humen & George Jablonsky & Jian-Ying Li & Jiang Hsieh &Ting-Yim Lee Received: 4 April 2011 / Revised: 23 August 2011 / Accepted: 25 August 2011 / Published online: 21 September 2011