The driver seat was lap-belt-equipped; the passenger seats were not. Dar knew that this was standard design for school buses. Parents who would never allow their children to ride unrestrained in their family vehicles happily waved good-bye to their children each morning in buses carrying fifty children and no passenger belts or harnesses. The estimated gross weight of this bus, the passengers, and their camping baggage was 22,848 pounds.
The driver had—as the newspapers and TV reports had put it—“a perfect safety record with the district.” Blood tests taken at the hospital immediately after the accident showed no evidence of drugs or alcohol. Dar interviewed her two days after the accident, and her account was almost word for word the same as the deposition she had given the CHP the evening of the crash. She reported that about one mile from their starting point, on a slight downhill grade, the bus brakes had “seemed weird and mushy.” She had pumped the brake pedal. A warning light had come on, indicating low brake pressure. At that point, the driver told him, the grade had changed from the downhill grade to a two-mile uphill climb and the bus began to slow. The automatic transmission had shifted to a lower gear and the brake warning light went off and then blinked a few times. The driver said that she assumed the problem had fixed itself at this point and that there was no reason not to continue.
Shortly thereafter, she reported, they entered the long downhill grade and the brakes “just failed completely.” The bus began picking up speed. The driver said that she could not slow it by using either the service or emergency brakes. Brake odor was strong. The rear wheels began smoking. She said that she had overridden the automatic transmission and shifted down to second gear, but that did not help. She said that she had then grabbed the radio to call her dispatcher, but had to drop the microphone in order to wrestle the wheel to keep the bus on the road. For six miles she succeeded, shouting at the students and teachers to “lean left!” and “lean right!” Finally the bus had contacted the outside guardrail, run along it, and gone over the embankment. “I don’t know what else I could have done!” said the driver during the interview. She was weeping at that point. Her report agreed with the interview testimony Dar had taken from the surviving teacher and students.
The driver—overweight, pasty-faced, and thin-lipped—seemed stupid and somewhat bovine to Dar, but he had to discount his own perceptions. The older he got and the longer he worked in accident investigation, the more stupid most people seemed to him. And more and more women tended to appear bovine in the years since the death of his wife.
His people checked the driver’s record. The TV stations and papers had reported that she had “a perfect safety record with the district,” and this was true, but it was also true that she had only worked for the district for six months prior to the accident. According to DMV reports from Tennessee, where the driver had lived before moving to California, she’d been issued one DUI citation and two moving violations in five years. In California the bus driver held a school bus certificate (passenger transportation endorsement) issued two days before her employment by the district and had a valid California class B (commercial driver) license restricted to conventional buses with automatic transmissions only. The California DMV records also indicated that ten days before the accident, the driver had two violations: failure to provide financial responsibility and failure to properly display license plates. CHP records showed that because of these violations, her regular driver’s license had been suspended. It had been reinstated the day before the accident after she had filed an SR-22 (proof of financial responsibility) with the DMV. She had no outstanding traffic warrants at the time of the accident. She had received 54 hours of instruction that included 21 hours of behind-the-wheel training in a bus similar to the crash vehicle, but the curriculum had no requirement for mountain-driving training.
Dar’s report on the physical damage to the bus ran to four single-spaced pages. Essentially, the bus body had separated from the chassis, the roof had collapsed and crushed inward from just behind the driver’s seat to the third row, the left side had crushed inboard, buckling and fracturing all of the window-frame supports and popping the glass out all along the left side, and the bumpers were missing. The fuel tank had been damaged in several places, one rubber fuel line had been cut, but the tank hadn’t been breached and its guard remained securely fastened to the chassis.
Dar reviewed the inspection and repair orders for the bus and found that the brakes had been adjusted every 1,500 miles and that the vehicle was inspected on a monthly basis. Although the last inspection had been only two days before the accident and the mechanic had stated that he found the brakes slightly out of adjustment and had ordered them to be adjusted, there was no record of the mechanics having adjusted the brakes. Safety Board tests of the accident vehicle’s brakes showed that they had been out of adjustment on the day of the crash. Further investigation showed that the school district had only recently switched over from the CHP California Code of Regulations inspection form to a company-developed form (1040-008 Rev. 5/91), and the chief mechanic had checked both the “OK” box and the “Repair” boxes on the form, initialing the “Repair” boxes. But unlike the older inspection form on which the order for further service was written in a space under the “Repair” box, the chief mechanic’s written work order had been scrawled on the back of the new form. The five mechanics working under him—there was one mechanic for every eighteen buses, as per school district and industry guidelines—had missed the handwritten work order.
“Well, that’s it, then,” said the superintendent of the Desert Springs School District.
“Not quite,” said Dar.
Three weeks after the accident, Dar staged a reenactment of the accident. An identical 1989 model TC-2000 school bus, loaded with 5,000 pounds of sandbags to simulate the weight of the students, teachers, and their luggage, was brought to the summit of Montezuma Valley Road at the national forest area where the classes had carried out their “Eco-Week” overnight camping trip. The brakes of this TC-2000 had been misadjusted to precisely the degree of error found on the accident vehicle. Dar designated himself as driver of the test vehicle and accepted one NTSB volunteer to ride along to videotape the reenactment. The California Highway Patrol closed the highway for the duration of the test. School Board members were present at the exercise. None volunteered to ride in the test bus.
Dar drove the vehicle down the first grade, up the two-mile uphill section, and then down the long canyon road—the worst grade was 10.5 percent—finally bringing the vehicle to a full stop at a pullout ten yards beyond where the accident vehicle had plunged off the highway. He turned the vehicle around and drove it back to the summit.
“The brakes worked,” said Dar to the assembled School Board members and CHP patrolmen. “There was no brake warning light. No smoke or smell of burning brake linings.”
He explained what had happened on the day of the accident.
The bus driver had left the national forest campsite with both of her emergency parking brakes set. After the first downhill stretch where they could smell the brakes burning, the next two miles had been uphill. “Brakes give off an odor,” explained Dar, “when the brake drum and shoes reach temperatures above approximately 600 degrees Fahrenheit.” The teachers, students, and driver had smelled the burning odor during both the first couple of downhill and uphill miles on the return journey. The driver had ignored the smell.