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Human Performance Factors Group Chairman's Factual report Goodland, Ks HWY16FH017 (16 pages)

Human Performance Group Chairman Factual Report · HUMAN PERFORMANCE FACTORS GROUP CHAIRMAN’S FACTUAL REPORT A. CRASH INFORMATION Location: Eastbound Interstate 70 at about mile

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  • Human Performance Factors Group Chairman's Factual report

    Goodland, Ks

    HWY16FH017

    (16 pages)

  • NATIONAL TRANSPORTATION SAFETY BOARD OFFICE OF HIGHWAY SAFETY

    WASHINGTON, D.C.

    HUMAN PERFORMANCE FACTORS GROUP CHAIRMAN’S FACTUAL REPORT

    A. CRASH INFORMATION Location: Eastbound Interstate 70 at about mile marker 30 near Goodland, in

    Sherman County, Kansas

    Vehicle #1: 2016 Volvo tractor in combination with 2007 Great Dane trailer

    Operator #1: Precision Truck Lines Inc., Sacramento, California

    Vehicle #2: 2004 Toyota Sequoia

    Date: June 29, 2016

    Time: Approximately 02:15 a.m. MDT

    NTSB #: HWY16FH017

    B. HUMAN PERFORMANCE FACTORS GROUP

    Sheryl Harley, Human Performance Factors Investigator, Group Chairman

    NTSB Office of Highway Safety

    490 L’Enfant Plaza East, S.W., Washington, DC 20594

    C. CRASH SUMMARY

    For a summary of the crash, refer to the Crash Summary Report in the docket for this

    investigation.

    D. DETAILS OF THE HUMAN PERFORMANCE FACTORS INVESTIGATION

    The crash discussed in this report involves the collision between 2016 Volvo truck tractor

    in combination with a 2007 Great Dane trailer and a 2004 Toyota Sequoia.

  • Goodland, Kansas – Human Performance Factors Factual Report Page 2 of 15

    The Human Performance factual investigation examined the behavioral, medical,

    operational and environmental factors associated with the two drivers involved in the crash.

    The focus of the investigation is on what influences fatigue may have had on the drivers’

    performance in the crash. A detailed accounting of the drivers’ activities; to include their

    work/sleep pattern, and the determination of his availability to obtain rest.

    1. Driver of the Volvo in combination

    1.1. Background

    The driver of the Volvo truck tractor, hereafter referred to as the truck driver, was a 27-

    year-old male who possessed a valid Class A commercial driver’s license (CDL) issued by the

    state of California. The truck driver has been operating commercial motor vehicles for 3 years.

    The accident carrier, Precision Truck Lines Incorporated, hired the driver on June 3, 2016 and the

    accident trip was his second trip for the carrier.

    1.2. The Truck driver’s training and qualification

    The truck driver received his initial training and certification to operate a commercial motor

    vehicle in 2013. The training school, where he received his certification, was operated by Swift

    Trucking Company, which subsequently employed the driver for an additional two months after

    his completion of the course. In addition to his employment with the Swift Trucking company, six

    other motor carriers, including the accident carrier in the last three years, have employed crash

    driver #1.

    As part of his pre-employment process with the accident carrier, the truck driver underwent

    a roadway check ride and found to be sufficient in his skills. The crash driver also presented to the

    carrier a certified copy of his traffic record from the California Department of Motor Vehicles.

    The record showed that the truck driver received a Class A CDL with “doubles-triples, combination

    tank, hazardous materials and motorcycle” endorsements. There were no restrictions on the

    license. The record also indicated a prior traffic violation in which the driver received a ticket and

    one prior non- commercial motor vehicle accident that occurred in 2008.1

    1 Human Performance Attachment 1: Truck driver’s California traffic record

  • Goodland, Kansas – Human Performance Factors Factual Report Page 3 of 15

    1.3. General Health

    On March 13, 2016, the truck driver underwent a commercial driver medical fitness

    examination at the U.S. Health Works clinic in California. His eyesight was found to be 20/20

    uncorrected and he passed the standard requirement for hearing. The truck driver had no significant

    medical history and qualified for a two-year medical certificate on that date. The medical

    certificate, received by the driver, indicated “Intrastate only” operation. The Kansas Highway

    Patrol cited truck driver for operating “interstate” on an intrastate medical certificate. Investigators

    contacted the issuing medical examiner. The subsequent investigation revealed that due to a

    clerical error, on the part of the truck driver, the medical certificate did not include interstate

    operation. The issuing medical examiner reported that the truck driver was eligible for an interstate

    medical certificate.

    1.4. Toxicology

    During the initial on-scene accident investigation, the truck driver denied the use of any

    alcoholic beverage, prescription medications or illicit drugs. A toxicological sample had been

    recovered by the Kansas Highway Patrol and sent to the Kansas Bureau of Investigation for

    analysis. The test results were negative for both alcohol and drugs.2 A search of records with local

    pharmacies, in and around truck driver’s place of employment and his residence, revealed no recent

    prescription history.

    2 Human Performance Attachment 2: Truck driver’s toxicology report

  • Goodland, Kansas – Human Performance Factors Factual Report Page 4 of 15

    Figure 1: P.C. Miler map of driver’s route from terminal to crash site.

    1.5. Activities prior to the Crash

    Information from several sources was used to establish the truck driver’s activities prior to

    the crash. Establishing a precise accounting of the truck driver’s location and activity was

    hampered by the driver’s attempt to hide his non-compliance with the regulations regarding

    mandated rest periods. An examination of the truck driver’s logbook revealed that over half of the

    entries had been falsified and the truck driver was unable to give a coherent accurate accounting

    of his movements. Utilizing other available sources such as the Volvo truck tractor’s “Pre-pass”

    toll/scale transponder, the bill of lading provided by the shipper and a fuel receipt, a reconstruction

    of the truck driver’s activity prior to the crash could be made.

    The trailer, attached to the crash truck tractor, left the shipper’s yard in Union City,

    California in route to Precision Trucking in Sacramento, California on Monday, June 27, 2016 at

    about 4:31 p.m. (PDT)3. The distance between the two points was 107.9 miles and would have

    taken a minimum of two hours to drive.

    3 Human Performance Attachment 3: Shipper’s bill of lading

  • Goodland, Kansas – Human Performance Factors Factual Report Page 5 of 15

    The truck driver took possession of the trailer at the Precision Trucking terminal and began his

    trip. The truck driver could not have started his trip before 6:30 p.m. (PDT).

    The Volvo truck tractor was equipped with a toll/scale pre-pass transponder that records

    the movement of the truck through the toll/scale houses in various states. A receiver at the toll/scale

    locations identifies the transponder assigned to a specific truck, identifies the individual truck by

    its VIN number and records the date and location the data was collected. The records are

    maintained by FasTrak Incorporated of San Francisco, California.

    Table 1 shows the data captured by FasTrak regarding the movement of the Volvo truck through the crash trip. The table shows the miles traveled between each data point and the minimum amount of time it would have taken to travel that distance.4

    Date Start location End location

    Distance Traveled

    Minimum time

    Verification

    June 27, 2016 Sacramento, CA

    Antelope, CA

    18.4 miles :24 Transponder

    June 27, 2016 Antelope, CA Carlin, NV 387.2 miles 6:36 Fuel receipt

    June 28, 2016 Carlin, NV Wendover, UT

    130.7 miles 2:12 Transponder

    June 28, 2016 Wendover, UT Evanston, WY

    199.7 miles 3:27 Transponder

    June 28, 2016 Evanston, WY Fort Collins, CO.

    372.0 miles 6:24 Transponder

    June 28, 2016 Fort Collins, CO

    Limon, CO 143.9 miles 2:29 Transponder

    June 28, 2016 Limon, CO Kanorado, KS

    91.4 miles 1:33 Transponder

    June 29, 2016 Kanorado, KS Goodland, KS

    19.6 miles :22 Transponder

    Table 1

    4 Human Performance Attachment 4: FasTrak scale/toll pre-pass records

  • Goodland, Kansas – Human Performance Factors Factual Report Page 6 of 15

    The crash occurred in Goodland, Kansas on Wednesday, June 29, 2016 at about 2:15 a.m.

    (MDT). The total distance from the trucking terminal to the crash scene was 1359.9 miles and

    requires a minimum of 23 hours and 20 minutes to drive. The earliest the truck driver could have

    departed the terminal on Monday, June 27th was at 6:30 p.m. (PDT). That would have given the

    truck driver 30 hours and 45 minutes to arrive at the crash scene.

    According to the transponder data, the truck driver traveled from the terminal in

    Sacramento, California to Carlin, Nevada via Interstate 80 Eastbound. During the initial crash

    investigation, members of the Kansas Highway Patrol recovered a fuel receipt from the truck

    tractor. The receipt shows that the truck was refueled in Carlin, Nevada on June 28, 2016 at 3:50

    a.m. (PDT). This was verified by fuel records obtained from Precision Trucking.5 The distance

    the truck traveled to Carlin, Nevada was 405.6 miles and would have taken a minimum of 6

    hours and 56 minutes to drive. The time available to make the trip was 9 hours and 20 minutes.

    This left a maximum of 2 hours and 24 minutes available for the truck driver to obtain rest.

    This was an insufficient amount of time to obtain the mandated rest.

    The distance from the refueling site in Carlin, Nevada to the crash scene was 957.3 miles.

    The amount of time available for the truck driver to make the trip was 21 hours and 25 minutes.

    The minimum amount of time that was required to drive that distance was 16 hours and 27 minutes.

    This left only 4 hours and 58 minutes available for the truck driver to obtain rest. The truck driver

    failed to obtain the required ten hours of rest.6

    The records showed that the truck driver was on duty and driving during the night time and

    early morning hours. This coincides with the lowest point of the truck driver’s circadian rhythm.

    1.6. Secondary Employment

    During an interview with the Kansas Highway Patrol, the truck driver reported that he

    worked part time for a moving company, known as Lugg.com, in addition to the accident carrier.

    5 Human Performance Attachment 5: Fuel purchase record 6 Human Performance Attachment 6: P.C. Miler Route report

  • Goodland, Kansas – Human Performance Factors Factual Report Page 7 of 15

    Lugg.com is an internet based, on demand moving company that provides services through an

    “Uber-type” mobile app.

    The company provides moving services for the greater San Francisco Bay area, San Jose,

    Palo Alto and Silicon Valley in California. Drivers, who are employed by the company, provide

    their own vehicles and are paid electronically at a fixed rate. A representative of Lugg.com was

    contacted and the company provided the employment records for the accident driver starting from

    his initial date of employment in January 2016. 7

    The truck driver advised that he does not record the hours he works for this second

    employer. Because of his failure to account for this “on duty” time at his secondary employment,

    the driver worked beyond his available work hours before the required rest period.

    The records show that while employed by Lugg.com, the truck driver worked during the

    normal daylight hours. This period would have coincided with the truck driver’s highest point of

    his circadian rhythm.

    The records, provided by the company, indicated that the truck driver worked a total of 40

    hours for this second employer prior to beginning the crash trip. The truck driver’s hours of service

    for Lugg.com is detailed below in Table 2.

    Date Times worked Total Hours Source

    June 22, 2016 1:00 p.m.- 8:00 p.m. 7 hours Lugg.com/driver

    June 23, 2016 11:00 a.m.- 7:00 p.m. 8 hours Lugg.com/driver

    June 24, 2016 11:00 a.m.- 7:00 p.m. 8 hours Lugg.com/driver

    June 25, 2016 9:00 a.m.- 4:00 p.m. 7 hours Lugg.com/driver

    June 26, 2016 9:00 a.m.- 7:00 p.m. 10 hours Lugg.com/driver Table 2

    7 Human Performance Attachment 7: Lugg employment records

  • Goodland, Kansas – Human Performance Factors Factual Report Page 8 of 15

    1.7. Driver Performance

    An interview was conducted with the truck driver at the time of the initial investigation by

    the Kansas Highway Patrol and a follow up interview was conducted a day later. The truck driver

    reported that he was in good health and not under a doctor’s care. During the subsequent interviews,

    he gave inconsistent accounts of his hours of service and the events of the crash. The truck driver

    reported that he went to bed between 8-9 p.m. (PDT), on Sunday, June 26th. He woke up on

    Monday, June 27th at 7:00 a.m. to get ready for work.

    The truck driver acknowledged that he did not include his secondary employment in his

    calculations of his hours of service prior to beginning the crash trip. The truck driver advised that

    he arrived at the terminal at 11:00 a.m. (PDT) and went on-duty. He advised that he began driving

    at 11:30 a.m. (PDT).

    Prior to the crash, the truck driver advised that he was traveling at a constant speed of 68

    miles per hour in the right lane. He advised that he had set the cruise control in the truck to that

    speed and the cruise control was in operation at the time of the crash. The truck driver advised that

    his headlights were on and in “low beam”. He advised that he had adequate light to see and no

    other conditions existed that obscured the roadway. The truck driver advised that the pavement

    was wet but not excessively slippery and presented no problem. He also advised that there were no

    mechanical issues in relation to the operation of the truck.

    The truck driver reported that he first observed the Toyota Sequoia in the right lane

    approximately a hundred feet in front of him. The truck driver advised that he could not determine

    whether the Toyota was stopped in the travel lane or traveling at an excessively slow speed. The

    truck driver advised that he did attempt to take evasive action to avoid the collision by applying

    the brakes and steering to the left. The truck driver stated that he came to a stop some distance

    away because he did not want to apply the brakes too aggressively and lose control of the truck.

    The truck driver advised that he got out of the Volvo truck and ran back to the Toyota, which had

    overturned in a ditch. The truck driver stated that he called 911 immediately.8

    The truck driver’s 911 call was received by the Emergency Communications Center at

    02:17 a.m. (MDT).

    8 Human Performance Attachment 8: KHP-Truck driver interview

  • Goodland, Kansas – Human Performance Factors Factual Report Page 9 of 15

    1.8. Driver Behavior

    The 49 Code of Federal Regulations outlines the requirement for rest for commercial

    vehicle drivers. The regulations exist to prevent driver fatigue. The truck driver was trained in

    these regulations and was employed as a professional driver for the past three years. Despite his

    training, the truck driver consistently violated the regulations and drove the commercial motor

    vehicle without obtaining the required rest. To hide his violation of the regulations, the truck driver

    falsified his logbook and maintained two sets of logs.

    1.8.1. Prior trip for Accident Carrier

    The truck driver reported that after Precision Truck Lines hired him on June 3, 2016; he

    drove one trip prior to the crash trip. The prior trip began on June 13, 2016 at 8:00 a.m. (PDT) and

    concluded on June 21, 2016 at about 11:30 a.m. (PDT) according to records provided by the

    accident carrier. An examination of these records revealed that the truck driver had falsified his

    hours of service and failed to get the required hours of rest. The truck driver was on duty or driving

    for a minimum of 112 hours out of a total 195 hours during the trip. The truck driver exceeded his

    allowable amount of on duty hours by 42 hours. The truck driver failed to obtain the required rest

    and was on duty or driving during the daytime and night time, early morning hours. The truck

    driver had inverted sleep hours and was on duty during the period of the lowest level in his

    circadian rhythm.9

    1.8.2. Cellphone Usage

    An examination of the truck driver’s cellphone records was performed. Though the truck

    driver used his cellular phone several times while the vehicle was in motion, the data showed that

    at the time of the crash, the truck driver was not talking or texting on the cellphone.

    Due to the falsifications in the truck driver’s logbook, it could not be determined if the truck

    driver used the cellphone at the time he attempted to obtain rest during the trip.10

    9 Human Performance Attachment 9: Truck driver’s logbook 10 Human Performance Attachment 10: Truck driver’s cellphone records

  • 11 Human Performance Attachment 11: Toyota driver's hospital toxicology report

    Goodland, Kansas – Human Performance Factors Factual Report Page 10 of 15

    1.8.3. Sleep Habits

    During the period of June 13, 2016 to June 29, 2016, the truck driver worked 16 consecutive

    days and a minimum of 171 hours. An examination of the truck driver’s logbook revealed that he

    habitually failed to obtain the mandated periods of rest. During this period, the truck driver worked

    three different shifts; alternating from working night time hours to daylight hours and then back to

    night time hours.

    The truck driver experienced periods of inverted sleep cycles and a rapid change in duty

    shifts that would not have allowed his body to adjust and would have affected his ability to obtain

    quality rest. This ultimately would have affected the driver’s performance in areas related to

    alertness, cognitive awareness, reaction time and coordination of body movement.

    2. Driver of the Toyota Sequoia

    2.1. Background

    The driver of the Toyota, hereafter known as the Toyota driver, was a 22-year-old male

    who reportedly was an undocumented person in the United States. The Toyota driver did not

    possess a valid license to drive a vehicle in the United States and his country of origin and his

    licensing in that country is unknown.

    2.2. Toyota driver’s skill and training

    This information is unavailable.

    2.3. General Health and Medical

    The Toyota driver’s general health prior to the time of the crash is unknown. During

    his admission to the hospital, he screened positive for methamphetamines and cocaine but

    confirmatory testing was not performed. 11

    Due to the Toyota driver’s medical condition, the Kansas Highway Patrol was unable

    to obtain any additional toxicology samples. The initial admitting medical facility had no

    residual samples to provide the NTSB for toxicology testing.

  • Goodland, Kansas – Human Performance Factors Factual Report Page 11 of 15

    2.4. Activity prior to Crash trip

    Interviews with the surviving occupants of the Toyota Sequoia and local law enforcement

    officials revealed that the Toyota driver was hired to transport undocumented persons from the

    Houston, Texas area to various locations in the southwestern United States. The Toyota driver was

    actively engaged in this employment at the time of the crash.

    2.5. Crash Trip

    The Toyota driver picked up his ten passengers in Houston, Texas on Monday, June 27th at

    approximately 10:00 p.m. The group left the Houston area at approximately 10:30 p.m. (local

    time).

    The Toyota Sequoia was designed to transport seven passengers. The vehicle was

    overloaded, and passengers sat incorrectly according to vehicle’s design. The “second row” seat,

    designed for three passengers, had four passengers occupying the space instead. The “third row”

    seat, designed for two passengers, had three passengers seated there. The rear cargo area, which

    by designed was not for human transportation, had two individuals who were seated on the floor.

    At the time of the collision, the Toyota driver and the front seat passenger were the

    only occupants wearing their seatbelts. Because of the impact with the Volvo truck, five

    passengers from the Toyota were ejected and one was partially ejected.

    Several of the surviving passengers of the Toyota Sequoia were interviewed. The

    passengers reported that the intended destination of the Toyota driver was Denver, Colorado. At

    that location, one of the passengers was due to be dropped off. The remaining passengers would

    travel to Los Angeles, California. 12

    The passengers reported that the Toyota driver stopped for several hours at a rest stop

    during the initial phase of the trip. The exact location was unknown to the group. After the initial

    stop, the Toyota driver stopped only to allow the passengers to receive restroom breaks and obtain

    food for the journey; which they were required to eat while on route.

    12 See Human Performance Attachment 12: Interview notes

  • Goodland, Kansas – Human Performance Factors Factual Report Page 12 of 15

    At the time of the crash, the Toyota driver was traveling eastbound on Interstate 70 in the

    opposite direction of his intended destination of Denver Colorado. The minimum distance from

    Houston, Texas to Goodland, Kansas is 890 miles. The minimum time it would have taken a driver

    to travel that distance is 17 hours. The exact route taken by the Toyota driver was unknown.

    The Toyota driver fled the hospital in Wichita, Kansas prior to being interviewed. Several

    attempts were made to locate and interview the driver without success.

    2.6. Driver Behavior

    One of the passengers of the Toyota Sequoia reported that the Toyota driver had been

    preoccupied with a mechanical issue with the vehicle. The passenger observed the Toyota driver

    utilize his cellular telephone to call his employer and report the problem with the vehicle. The

    passenger overheard the driver being instructed to solve the problem while on route.

    The passenger reported that the vehicle had begun to lose power and had slowed noticeably. In

    addition to the decrease in power, there was an uncharacteristic metallic sound coming from

    underneath of the vehicle.

    Despite the problem with the vehicle, the Toyota driver continued to drive, and the vehicle

    was in motion at the time of the crash. The exact timing of the telephone call between the Toyota

    driver and his employer is unknown. The Toyota driver’s cellular telephone, recovered from the

    scene, was too badly damaged to provide any information. The investigation by the Kansas

    Highway Patrol is still ongoing.

    3. Environmental Factors

    3.1. Crash Location

    The accident site is located approximately 30 miles east of the border with the state of

    Colorado on Interstate 70 East near Goodland, Kansas in Sherman County.

    The roadway is a four-lane highway with an earthen median that separates the two

    eastbound lanes from the two westbound lanes. The roadway has two shoulders in each direction,

    divided by a single white fog line. A grass embankment is located adjacent to the right shoulder.

    The roadway is straight and level at the location of the crash.

  • Goodland, Kansas – Human Performance Factors Factual Report Page 13 of 15

    The roadway pavement was wet due to the rain, which had stopped approximately one hour

    prior to the crash. The posted speed limit is 75 miles per hour.

    Photograph 1: Kansas Highway Patrol daytime crash scene (looking westbound)

    3.2. Weather

    The area surrounding the crash scene, according to the National Weather Service, had

    reported rain fall that had stopped one hour prior to the crash. The last reported weather data was

    captured at 1:53 a.m. (MDT), approximately 22 minutes prior to the crash. See Table 6 for the

    weather recorded for the area of Goodland, Kansas.

  • Goodland, Kansas – Human Performance Factors Factual Report Page 14 of 15

    Weather

    Time recorded: 1:53 a.m. MDT

    Temperature: 62 degrees F

    Dew Point: 57.9 degrees F

    Humidity: 86%

    Pressure: 30.04 inches

    Wind direction: East

    Wind speed: 5.8 mph

    Visibility: 10 miles

    Precipitation: None

    Table 6

    E. DOCKET MATERIAL

    The following attachments and photographs are included in the docket for this investigation:

    LIST OF ATTACHMENTS

    Human Performance Attachment 1- The truck driver’s California traffic record

    Human Performance Attachment 2- Kansas Bureau of Investigation Forensic Lab report

    Human Performance Attachment 3- Shipper’s bill of lading

    Human Performance Attachment 4- Fastrak Scale/Toll Pre-Pass records

    Human Performance Attachment 5- Truck driver fuel purchase detail sheet

    Human Performance Attachment 6- P.C. Miler Route report

    Human Performance Attachment 7- Lugg employment records

  • Goodland, Kansas – Human Performance Factors Factual Report Page 15 of 15

    Human Performance Attachment 8- KHP- Truck driver interview

    Human Performance Attachment 9- Truck driver’s logbook

    Human Performance Attachment 10- Truck driver’s cell phone records

    Human Performance Attachment 11- Toyota driver's hospital toxicology report

    Human Performance Attachment 12- Interview notes

    LIST OF PHOTOGRAPHS

    Human Performance Figure 1- KHP daytime scene photograph looking westbound

    END OF REPORT

    Sheryl Harley Highway Accident Investigator

    Human Performance Factual Goodland, Kansas.pdfA. CRASH INFORMATIONB. HUMAN PERFORMANCE FACTORS GROUPC. CRASH SUMMARYD. DETAILS OF THE HUMAN PERFORMANCE FACTORS INVESTIGATION1. Driver of the Volvo in combination1.1. Background1.2. The Truck driver’s training and qualification1.3. General Health1.4. Toxicology1.5. Activities prior to the Crash1.6. Secondary Employment1.7. Driver Performance1.8. Driver Behavior1.8.1. Prior trip for Accident Carrier1.8.2. Cellphone Usage1.8.3. Sleep Habits

    2. Driver of the Toyota Sequoia2.1. Background2.3. General Health and Medical2.4. Activity prior to Crash trip2.5. Crash Trip2.6. Driver Behavior

    3. Environmental Factors3.1. Crash Location3.2. Weather

    E. DOCKET MATERIAL