The investigation of the serious bus accident in Kuopio on 24 August 2018 that lead to four people losing their lives and 19 getting injured is complete – the safety of the entire bus sector must be improved
On 24 August 2018, a serious accident occurred in Kuopio in which a bus leaving a motorway exit fell off a bridge and onto a railway track. Four passengers died. Additionally, nine persons were seriously injured and ten were slightly injured. Based on the investigation by the Safety Investigation Authority, Finland and earlier observations, there are deficiencies in the safety of the bus sector that can and must be corrected in order to improve the safety of the entire sector, the passengers and everyone travelling on the roads.
The driver’s alertness was lowered by his state of health and, given this, the heavy nature of his duties. For this reason, he failed to observe the oncoming intersection and also failed in his attempt to brake. The driver had driven the buses of the company in question only randomly, had only a little experience of the vehicle involved in the accident and poor familiarity with its controls. The ramp was very short and had no signs indicating that drivers should lower their speed other than an urban area sign. In addition, the view of the intersection was hampered by trees between the motorway and ramp. Together, these factors contributed to the accident. The deaths and serious injuries were a result of the vehicle falling down onto the train tracks from a height of around ten metres. The bus had no technical defects that would have contributed to the accident.
Six safety recommendations for improving the safety of the entire bus sector and road traffic
The Safety Investigation Authority recommends that the Ministry of Transport and Communications draw up regulations helping in the adoption of a safety management system in the entire bus sector.
Most bus companies lack documented safety management that would enable the systematic improvement of safety. With the help of the system, the companies could assess the key risks and prepare a plan to alleviate them. Things that are needed include arrangements for choosing the driver according to the task, proper occupational health care, good planning of work shifts, and a bus fleet that is as safe as possible. A good system also includes learning from accidents and dangerous situations.
- A documented safety management system allows the transport clients to assess the safety of the service in addition to its price. However, the development of safety management systems has been regrettably slow in the bus sector. In other forms of transport, such as aviation, rail transport and marine transport, there has been better progress. Safety management should be promptly put in order in the bus sector, too, states Investigator-in-charge Kai Valonen.
Secondly, the Safety Investigation Authority recommends that the university faculties providing medical training ensure that the basic, specialisation and complementary training of physicians include the basics of driver health. In particular, the objective must be that physicians are familiar with the special characteristics of the driver profession, the driver health requirements and the effects of driver health on safety. The training currently varies by university and is rather scant.
The driver's chronic illness contributed to the accident. The issue was known during health care contacts and driving license examinations, but this did not lead to a closer examination of the illness or more frequent check-ups. It appears that the special characteristics of the bus driver's profession are not sufficiently taken into account during check-ups. The profession of a bus driver is safety critical, so particular care must be taken of their ability to function. The vehicles do not have a second driver, and the vehicle systems are currently unable to provide sufficient assistance.
Thirdly, the Safety Investigation Authority recommends that the Finnish Transport and Communications Agency amend the driver health instructions by adding the identification of hyperglycemia, or high blood sugar, and the measures it requires, particularly with respect to professional drivers. During the investigation, it was found that there is only a brief mention of this issue in driver health instructions although research data exists on the problem. Chronic or acute hyperglycemia may adversely effect attentiveness, perception and the ability to process information. These symptoms affecting the functioning of the nervous system may be sudden or longer-term in nature. The issue is often not investigated in accidents, so hyperglycemia likely contributes to accidents more often than is currently known.
The Safety Investigation Authority also recommends that the Ministry of Transport and Communications check the requirements and practices relating to the monitoring and safeguarding of the state of health of bus drivers and ensure that the likelihood and consequences of losing the ability to function are managed in the same manner as with other modes of transport. Attention must also be paid to psychiatric health and fatigue management.
The driver's state of health was crucial to the Kuopio accident. Health-related dangerous situations were also brought up in the theme investigation on accidents involving buses, published in 2017 by the Safety Investigation Authority. During the eighteen-month monitoring period, there were 13 incidents involving problems in the bus driver's ability to function. The loss of the ability to function is dangerous, as the vehicle will become uncontrolled, at times at a high speed. This places the driver, passengers and bystanders at risk.
- The monitoring of health is more comprehensive in aviation, marine transport and rail transport than in road passenger transports. The differences in ensuring driver health that are specific to the mode of transport are not justifiable from the perspective of safety. The aging of the driver pool also increases the need for monitoring. The monitoring and safeguarding of driver health must be promptly put in order in the entire bus sector, emphasises Veli-Pekka Nurmi, Executive Director of the Safety Investigation Authority.
Furthermore, the Safety Investigation Authority recommends that the Finnish Transport Infrastructure Agency identify the locations in the road network involving the possibility of a heavy vehicle falling off and plan corrective measures in co-operation with the municipalities and ELY Centres. Such measures include the removal of obstructions of visibility, guidance for a speed suitable for the situation, improvements in the geometry of the ramp and the intersection, and additional railings slowing down speed at various points.
The consequences of the accident were severe, because the bus fell off the bridge from a height of around ten metres. Correspondingly, the accident that resulted in the deaths of four persons in Heinola in 1999 resulted from the bus plunging down an embankment nearly ten metres tall. In both cases, the vehicles were travelling at a high speed upon arriving from a motorway ramp to an intersection. Tens of cases of buses going off the road occur each year, but only seldom do these accidents result in passenger deaths. Mortal injuries are not usually sustained even when the bus falls over, so the possibility of falling must be prevented in particular.
As the sixth safety recommendation, the Safety Investigation Authority recommends that, in its international co-operation, the Transport and Communications Agency actively promote collision alarms, emergency braking systems, lane guards and equipment monitoring the driver's alertness – all equipment that has already become established in the market – becoming common in buses. Due to the possibility of a major accident, there are grounds to require more safety equipment in buses than in other vehicle categories.
In bus transport, the safety of a large number of persons depends on the driver to a significantly large extent. After all, all human activity involves the possibility of mistakes against which there is less technology in road traffic vehicles than in other modes of transport. Railways have automatic train control. In addition to technology, aviation and maritime transport also have a second professional in the cabin or on the bridge. A collision alarm and an automatic emergency braking system could possibly have prevented the accident that occurred or alleviate its consequences. The development of vehicle technology has commonly improved traffic safety. Examples of these include anti-lock brakes, airbags and electronic stability control. There is cause to speed up positive development.
Kai Valonen, Investigator-in-charge, tel. +358 (0)295 150 707
Veli-Pekka Nurmi, Executive Director, Docent, tel. +358 (0)295 150 701