FURTHER RESPONSES TO NTSB REPORT OF SEPTEMBER 21, 1999

Letter to NTSB Chairman, Jim Hall  October 17, 1999

This letter is to request that you use your position to ensure that the final Bus Crashworthiness Special Investigation is fair and unbiased. My wife and I attended the August 12, 1998 hearing in Las Vegas as representatives of National and Florida PTA. We submitted commentary on that hearing, reviewed the technical draft, and I attended the public meeting on September 21 of this year. We are the co-authors of resolutions adopted by National and Florida PTA in favor of seat belts on school buses, and are co-chairs of the Florida Chapter of the National Coalition for School Bus Safety.

We entered into this process without illusions, but hoped that the NTSB would conduct its inquiry in an objective and competent manner. This has not been the case. While we applaud the Board's initiative in undertaking the investigation because of evidence indicating that compartmentalization was inadequate, bias against seat belts on large school buses has been evident throughout the process. There have been glaring deficiencies in the gathering and analysis of evidence. There were an appalling number of significant errors in the technical draft. And NTSB staff was complicit in ensuring the focus of the September 21 public meeting was shifted from the finding that compartmentalization was incomplete to the simulation's indication that seat belts might pose a danger. My reasons for making these accusations follow:

Bias
Bias defeats scientific investigation because it predisposes the investigator along some lines of inquiry to the exclusion of others in order to arrive at a preferred conclusion.

The original panels were one sided. There were no representatives who were familiar with, or willing to acknowledge, United States studies or portions thereof, favoring seat belts. These studies include the NAS Transportation Research Board Special Report No. 222 which says that seat belts are "not inherently harmful" and may offer improved safety performance of up to 20% with only 50% of passengers using them; the U.C.L.A. crash tests and reports of 1967 and 1972; Trauma Research Group, University of California, "Bus Collision Causation and Injury Patterns"; two New York Legislative Commission Reports on Critical Transportation Choices: "School Bus Safety in New York State", 1985; and "Increasing School Bus Safety for New York State's Children through Seat Belts on School Buses and the Elimination of Standees!", 1986; New Jersey Institute of Technology, "School Bus Safety Belt Study" 1989; and "Seat Belts and School Buses" Madison-Oneida Board of Cooperative Education Services, 1994

There was no representative from New York, New Jersey or any of the districts across the country that have experience with seat belts. Representatives from these districts could have responded to allegations about belt use, the need for monitors, the potential for injury posed by seat belts, etc. No one was there from Entobicoke, Canada where lap belts have been required since 1975.

There was no representative from the American Academy of Orthopaedic Surgeons, the AMA, or any of the many medical organizations with positions favoring seat belts. Dr. McElhaney's position is opposite to that held by the AAOS.

American researchers of the subject who favor belts were excluded. Dr. Agran was a party on behalf of the American Academy of Pediatrics, but was limited to asking questions. Other potential researchers who were excluded include Kathleen Weber of the University of Michigan, a member of the Transportation Research Board that issued Special Report No. 222, whose paper on the misuse of lap restraints is referenced in the 1989 NTSB study on the Crashworthiness of Small Poststandard Schoolbuses, Dr. Russell Fine, University of Alabama, Director, Injury Prevention and Research, and Dr. John States, University of Rochester, (retired). Dr. Kecman, Mr. Makeham, and Mr. Strumane were insufficiently familiar with the FMVSS 222 seat to give balance to the panels on the issue of belts on those seats.

The composition of the parties to the August 12 hearing was also skewed against belts on buses. The Government party, NHTSA, despite its officially neutral position has consistently discouraged rational inquiry on the subject, dispensed misinformation to lay persons, and continues to publish quotations from NAS Special Report No. 222 selected to support the anti-belt side of the question, consistently omitting pro-belt portions. No reasonable person could consider them to be neutral. The Research/Medical table was composed of pro seat belt parties: Dr. Agran of the American Academy of Pediatrics and Dr. Ross of the National Coalition for School Bus Safety represented organizations with stated positions. Our participation, representing the 6.5 million PTA members who have adopted a resolution in favor of belts, was subsumed under the aegis of the NCSBS, as was Ms. Tombrello's for SafetyBeltSafe. I do not know whether the Association for the Advancement of Automotive Medicine has a position pro or con. The school bus table was all anti-belt; the National Association of State Directors of Pupil Transportation Services, National Association of Pupil Transportation, National School Transportation Association and Blue Bird were all opposed. The Motorcoaches and Transit parties were essentially neutral on school bus issues and made a point of distinguishing motorcoaches and transit buses from school buses. The ratio of anti-belt parties to pro-belt parties was therefore six to two. The advantage of the anti-belt groups was two to one in the questioning because of the spokesperson arrangement for the tables.

Evidentiary Deficiencies
Mr. Rick Downs, the first NTSB investigator on the scene of the Monticello, MN accident made outrageously inaccurate statements to the community at a public meeting, asserting that seat belts might have caused greater injuries, even "lateral bisections," prior to the completion of the study. His statements reveal a prejudice on the subject and therefore make the data he developed suspect. Since these data presumably informed the assumptions made in the simulations, the results of those simulations must also be suspect.

The questioning process at the August 12 hearing was unsatisfactory. The person chosen by the NTSB to forward the questions of our table was given the impression that each table was limited to a certain number of questions and therefore felt it necessary to edit questions from ourselves and others at the table. There was no opportunity to follow up or challenge misinformation proffered by panelists. This had the effect of suppressing some information and allowing for the acceptance of misinformation.

The review of the technical draft that would have allowed for oral questioning of staff was changed to multiple independent written reviews of the document. Oral questions would have been particularly useful in enlightening the parties to the hearing about the computer simulations and what the real facts surrounding the different accidents were. None of the questions we posed in our review of the technical draft have been answered as they presumably would have been at a face-to-face meeting. This precluded follow up questions based on clarifications that might have been offered by staff. Limiting the parties to written reviews diminished their comprehensiveness.

Technical Draft Deficiencies
We requested a second technical review because the draft had so many inaccuracies and discrepancies it was impossible to fully assess it. We could not address the "factual" information because the draft usually had two opposing versions of the "facts". This naturally leads to a suspicion that perhaps neither version is correct. Without any evidence to the contrary, the entire completed report is suspect.

A similar problem exists with respect to the computer simulations. The draft raised a large number of questions about the validity of the assumptions, the appropriateness of the models, and the capacity of the software to render an accurate representation of real world events. The choice of simulated dummy sizes that do not match those of the actual passengers precludes a comparison of the simulation with the actual accidents for comparative purposes and raises methodological problems with respect to the predictions of the performance of the lap shoulder belted passengers in the Monticello simulation.

The description of the injuries of one fatally injured passenger in the Monticello accident, Kristine Burzinski (#21), makes no reference to which side of her body suffered injury. "Table 2 - Actual injuries sustained by bus occupants" on page 33 of the draft describes her injuries thus: Fractured skull, extravasation of dura matter; Splenic rupture; Pulmonary contusions w/ respiratory failure; Fractured mandible; and Fractured pelvis. This description of her injuries is abbreviated and omits whether they are on the right or left. Significant additional information is available in Kristine's autopsy report. The comminuted skull fracture that led to the lacerations of the right frontal pole of the brain was over her right eye. The mandible was fractured between teeth number 27 and 28 on the right side. And the pelvis was fractured at the pubis symphysis (center of the body) and the right ischium. This information is significant because Kristine was sitting on the left side of the bus. Injuries to the right side of her head, jaw, and pelvis suggest that being thrown from her seat to the opposite side of the bus may have caused her death. This possibility is not addressed in the draft, and especially not in the simulation.

BriAnn (#21a), the passenger next to Kristine, has stated that they were both sitting facing forward at the time of the accident. She was not interviewed by the NTSB. The first witness on the scene, Mr. Marn Flicker, a retired Monticello Fire and Rescue worker, was not interviewed until eight months after the accident. He was only contacted after CNN had interviewed him. Mr. Ingeman who lived across from the corner where the accident took place and called 911 was never interviewed. It is difficult to reconcile the need for complete information with the above apparent derelictions. Informed opinion cannot be predicated on incomplete and inaccurate information.

Complicity with anti-belt faction
The public interest was not served by an orchestrated series of leaks just prior to the September 21 meeting. These leaks about the predictions of the computer simulation and suppositions about the efficacy of belts on buses were allowed to flood the media with no countervailing focus on the actual conclusions and recommendations of the report. This resulted in a coup for anti-belt forces. During the post-meeting press conference there was no attempt to correct the misinformation that had been publicized. No attempt was made to tell the public that there were no recommendations for stronger flooring (as reported by a number of news outlets) or that the NTSB had not taken a position on belts one way or the other. Instead, you and your staff defended the substance of the leaks, ignoring the actual conclusions of the report!

In particular, there was no attempt to focus the media on conclusion number 5 "It cannot be determined whether the current design of available restraint systems for large school buses would have reduced the risk of injury to the school bus passengers in the accidents simulated for this special investigation." Neither was there an effort to focus on conclusion number 1: passengers in the seating compartment (not in the impact zone) suffer fewer injuries; number 3: Current compartmentalization is incomplete, or recommendation number 3: develop performance standards for school bus occupant protection systems within two years, and number 4: require new buses to incorporate those systems when available.

While the NTSB obviously has no control over what is reported, the venue of a press conference was the perfect opportunity to correct misinformation that had been publicized immediately prior to the event. It was the height of irresponsibility to allow the imprimatur of the NTSB to legitimatize the machinations of a publicist. Confidence in the Board's ability to provide accurate and dependable information to the public is seriously compromised.

The leaks should not have happened. When we received the technical draft for review, it came with a unilaterally imposed confidentiality that we chafed under, but honored. The member(s) of your staff who leaked the information related to the simulations and the animated presentations thereof betrayed the Board and the public. They should be censured and disciplined. Yet, your comment on the report to staff was to thank and congratulate them.

It is my earnest hope that you will seriously consider the issues raised in this letter and engage in an effort to ensure the legitimacy of the final report. The conclusions and recommendations that were released on the 21st are encouraging. They imply that at least some of the above mentioned deficiencies have been rectified. However, the events surrounding the public meeting coupled with a conspicuous absence of corrective efforts on the Board's part prevents optimism about the final report. I hope you will review the language of the complete report with an awareness of how it will be perceived by the public. The report should state clearly which portions represent findings that lead definitively to conclusions and which portions are based on conjecture. Such a report will fulfill the function for which the NTSB was created and improve safety for the children of America.

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