Monday, February 04, 2013

Why the bus crashed

Over two dozen people were injured in a bus crash on Boston's Soldiers Field Road this past Saturday evening when a too-tall bus tried to go under the Western Avenue underpass.  WCVB-TV tweeted:  "Three passengers are in critical condition at BMC [Boston Medical Center] and Brigham & Women's; 29 others suffered non-life-threatening injuries"  Above is a picture from the Boston Fire Department.

The BFD tweeted that 60 firefighters and "many, many" EMS folks came to the rescue: "Professionalism at its highest level at this incident by all first responders."

Universal Hub reported:

The bus had just left Harvard on its way to Pennsylvania with 42 people on board, from a non-profit group's day trip to Harvard and Harvard Square. Federal records show Calvary Coach is a small charter company based in Philadelphia - with just two buses. He was taking some Pennsylvania students from a tourist visit to Harvard Square and had chosen to head downtown on Soldiers Field Road.   

UHub said:

WPVI in Philadelphia talked to the owner of the bus that crashed into the Western Avenue overpass last night:

"He said he looked at the GPS, looked down to make the turn and when he looked back up, the bridge was a low bridge, he hit the low bridge," said Talmedge. 

Massachusetts State Police, however, say the driver should never have been there in the first place and that the entrances to Soldiers Field Road all have warning signs.

Within moments, judgements were coming in on the Internet:  "Buses are not allowed on that road. There are signs everywhere. Hang the bus driver."

Some were sympathetic, though: "I don't think native Bostonians understand how bizarre the low bridges on Storrow/Soldiers Field are to non-natives."

Let's do the root cause analysis:

Here's the view of the entrance to Soldier's Field Road that you would have seen if you were the driver:

 In contrast, here's what you would see if you enter Storrow Drive just a mile or two down the road:

I told this story in my book Goal Play!  Here's an abridged version:

When Bill Geary took over as Commissioner of the Metro­politan District Commission (the regional parks and roadway agency for the Boston area) in 1983, he noticed an odd traffic phenomenon. About once a week, a truck that was too tall would enter one of the two main roads along the Charles River and attempt to go through the underpasses below the main bridge crossing at Massachusetts Avenue. Those underpasses had only ten feet of headroom. The truck would hit the bottom of the bridge assembly, its roof would roll up like the top of a sardine can, and it would get stuck, blocking one or both of the two lanes of traffic. Traffic would back up two miles or more. The MDC police and road crews would go to work, rescue the truck driver, deflate the tires, and tow the truck away. Meanwhile, thousands of drivers would be delayed. 

He said to his staff: “What if,” he said, “we put signs up at every entrance to the river roads, at the height of the underpasses, with a pictogram warning taller trucks to stay out?”

“Commissioner,” someone replied, “Can you imagine the liability if our sign breaks a windshield and sends glass flying into the face of a truck driver?”

“Well, what if we make the signs out of rubber so they don’t break the windows?”

“But Commissioner,” someone said, “What good is a rubber sign? Truck cabs are noisy places. A trucker will just hit the sign and drive right through without even hearing that he has hit it." 

“Well, then, let’s hang cow bells on each sign, so drivers will hear a noise as they approach our roadway if their vehicle is too high to go through the underpass.” 

“Where will we get cow bells?” he was asked.

“I don’t know. Call a dairy farmer and ask where they get their cowbells.” 

The signs were installed, cow bells and all. The frequency of crashes in the underpasses went from one per week to less than one per year. Absent Bill’s persistence and personal involvement, we would still be cleaning up those weekly truck crashes three decades later.

Now, look at the two pictures again. Do you see those lonely chains hanging down from the Soldiers Field Road entrance sign?  There used to be a rubber sign (and cowbells!) there--placed carefully at the height of the Western Avenue underpass.

In contrast, now, all you have is a sign--way up high--indicating that there is a low bridge ahead.  It does not tell you the height of the underpass, and by the placement of the sign, most people would assume that it is pretty high up.

Now, imagine you are an out-of-town bus driver, with a busload of noisy kids, driving at night, using your GPS to find your way to the Massachusetts Turnpike.  While we can find fault with the driver if we want, I think we have to acknowledge that what happened to him could happen to anybody.

Here, as in the hospital world, the phrase, "what happened to him could happen to anybody," is usually evidence of a systemic problem, not a personal problem.  The Commonwealth of Massachusetts solved the problem of bus crashes on this road 30 years ago.  A lack of maintenance or will or understanding on the part of the state administration caused this problem to recur this past weekend.  It was, in a sense, inevitable.

And it will happen again and again unless the state agency gets it act together.


Jason said...

Wow, I remember the story from the book. Being that I have driven in Boston it was confusing and I can’t imagine that any bus driver would suspect a low underpass unless they had seen it before.

Warren Bush said...

From Facebook:

I love what you write here, and I see so many situations to which it applies:
" ..., `what happened to him could happen to anybody,' is usually evidence of a systemic problem, not a personal problem."

RalfLippold said...

Mental models force us always to run in "automatic mode" despite the current live context.

Years ago I witnessed the production of 400 (!) products of a value of almost 40,000 € at least each getting scratches (1 mm deep) so it could have been seen by anybody in the production line. But it needed 400 (!) to go along unseen only to be inspected thoroughly, and production put to a halt (399 standing scratched in the production line). Don't ask who got the blame (it was not the system set up the least to say).

People always underestimate the probability of things that should not happen due to mental models on which we as humans run on "normally" quite well in standard environments.

Thanks Paul for this rather shocking, and yet eye-opening story that could happen to anybody of us (just imagine having bikes on the roof and entering a parking garage with a clearance of 2.50 m - no doubt there will happen something unexpected when it is the first day of the holiday, and you are heading South).

POPS said...

actually, the first photo is the view if you were already on Soldiers Field Road. If that map route is accurate and the driver was making a left turn off JFK St under that sign then it was even harder to notice that sign at night...

Paul Levy said...

You are correct, POPS!

Redd said...

Great article! Thank you.


massmotorist said...

This is what happens when an agency tries to be all things to all people.

DCR handles parks and recreational facilities. They have always handled roads in a haphazard and arbitrary manner. The state DOT has the resources, standards, and procedures to manage roadways in an appropriate way, because they're in the business of doing so, and they should take over most DCR "parkways".

Se7en said...

Where did you get the photo of the sign misssing? was that taken yesterday?

Paul Levy said...

I took the pictures yesterday, Sunday, at 9:15 am.

JD&B Dad said...

You are correct. BUT. Some of the best advice anyone ever heard came from the U.S. Coast Guard and is printed on official charts for finding your way on water: "The prudent navigator will not rely solely on any single aid to navigation"

DCR (the successor to my old employer the MDC) should do as you suggest and put back up Bill Geary's rubber signs and cowbells. And bus drivers should plan their routes in advance, getting local advice about best route.

Also, Google, Navteq, etc . . . that give navigation advice without little parenthetical notations about "cars only" have some responsibility here. Could be interesting if use of maps and data prepared by government was conditioned on folks who use it warning drivers about limitations on roads. They might even do that voluntarily!

Paul Levy said...

Hmm, I thought the highways had been transferred to DOT, but I may be wrong. But, the MDC made the improvements when it was also running the parks and swimming pools and skating rinks.

Anonymous said...

I thought of those signs as soon as I heard the news. So sad.

Ron Newman said...

Is it possible that the CARS ONLY sign was missing Sunday morning because the bus had hit it and knocked it down?

Paul Levy said...

I don't think so, as I have seen several missing.

Pat Thomas said...

I wonder if the driver could read English.

Paul Levy said...

Dunno, although it is likely a requirement for a commercial driver's license. By again, if the rubber sign had been in place, language would not have mattered.

massmotorist said...

They transferred all of DCR's bridges to MassDOT, along with several DCR roads, but various environmental groups had concerns about transferring Storrow and other parkways and blocked their transfer. They feared that MassDOT would emphasize cars and roadways over the parks (IMO, an overblown concern).

I agree that it's quite possible for good managers to do the right thing, but the problem is institutional culture. DCR is and probably always will be an organization focused on conservation and parkland, with transportation a secondary focus at best. It lacks the scale, institutional memory and specialization, and highway engineering expertise of a DOT.

DOTs have a culture of safety and standards that focuses on engineering solutions and prevention, such as Roadway Safety Audits. DCR often has a "blame the driver" mentality that focuses on enforcement and empty gestures such as lower speed limits. That's not because there aren't good people there, it's just that they don't have the engineering expertise to know better.

Anonymous said...

I read the news, sad, and found hope in your analysis. These things
can be prevented!

David said...

Fascinating and sad.

Anonymous said...

Paul, if you've seen other missing signs, *please* report them to the DCR ASAP!

Paul Levy said...

Sorry, I am under strict orders from my doctor to never use my cell phone while driving.

DCR has vehicles running up and down the river roads all day long. Perhaps their own employees can be asked to report deficient signs and other safety-related equipment. And they have CB radios they can use right on the spot!

Phil said...

What a shame, and there is no reason that this might not happen again this week.

Anonymous said...

Since this is ostensibly a health care blog, may I add that there is a lesson here for health care also. Many are the times when I was investigating a medical error and old-timers would tell me, "Well, we used to have a (insert solution), but so-and-so left and then nobody ever took care of it again, so it got dropped." We find ourselves solving the same problems over and over and over again. One must be utterly relentless to make sure things (and rubber signs) don't get dropped over time.

nonlocal MD

Paul Levy said...

Exactly right!

Paul Levy said...

Some people, though, continue to miss the point. Here is one such comment from Universal Hub, which picked up this post.

This is Boston, not Dubai. It's old. Even the new roads are old. They were not made for the monster vehicles that have taken over the US.

Every year there are trucks jammed under overpasses in Boston. Some of these stories even make the national news. If I was planning to be a tour bus driver that makes trips into Boston, I'd be aware of this.

The driver's ignorance/inability to pay attention to signs, GPS, maps, cowbells, flashing lights, leaping gnomes or whatever else is not the State's fault, nor is it the city's fault.

It's his fault.

Paul Levy said...

And another:

Professional drivers need to be professional. Put up cowbells, or whatever you want but at the end of the day if you are licensed as a professional driver of large vehicles like semi's or tour buses, you need to drive responsibly. Being lost in a city you don't know in your Honda Accord is one thing; a huge bus filled with people for whose safety you are responsible is another. Plan things out, slow it the hell down, especially in the dark.

There are atlases (the old dead-tree variety) that map out height and weight restrictions for truckers. I imagine some of these have been put into navigation systems, but maybe not -- my trucking days are well in the past (great business opp if so). Regardless, you should plot out your route ahead of time taking into consideration the limitations of your vehicle (or the roads it will travel on, as the case may be).

Now college students from out of town renting a U-Haul....ok, that's kind of expected. Professional truckers, coach drivers, etc., that's not acceptable.

Size, color of the sign; flashing lights on a height trigger; hanging mudflaps, cow bells or explosive goat carcasses - whatever. You're driving a huge vehicle, pay attention, because the road conditions won't pay attention for you. Do tall people need dangling bells in front of low doorways? If it's really hobbit-like you put up a sign and hope Goliath can read.

Anonymous said...

I would not disagree that more effective signage might have reduced the likelihood of this accident occurring. However, this bus driver committed two egregious errors for a professional driver. First, as noted in other comments, he appears not to have laid out a route ahead of time even though he was not familar with the area. Second, he apparently was not looking where he was going when the accident occurred - how can you drive a bus while your eyes are off the road you're heading down?

Sj said...

On the NPR program "Radio Boston" today they ran a segment titled, "Tall Vehicles, Low Bridges". There were two points that were both interesting and relevant to this discussion. First, they spoke with SJ Port, spokesperson for the DCR. She says that the cow bells on the rubber signs were deliberately taken down in 1990 because, when blown around by the wind, they were creating confusion and more problems than they were solving. Then they spoke with 2 people from a local company called TeleType Co. who have created and are marketing a GPS program specifically designed for commercial vehicles. This program takes into account roads that are closed to trucks and buses and heights of bridges, underpasses and other similar hazards. So, it seems we're not dealing only with a lack of maintenance (though that seems to be the case for the missing "Cars Only" sign), but a difference of opinion. The GPS solution sounds like a very good one, but now it's a quesiton of ensuring wide-scale implementation. A link to the audio of the segment:

Paul Levy said...

OMG, now we start to rewrite history and then engage in bureaucratic solutions.

First of all, the signs and bells were extremely effective for many years. Secondly, the bells have not all been taken down. There are still a number of locations where they can be seen, e.g., at the base of the Longfellow Bridge where you turn onto memorial Drive. (I have a photo of that set in my book, taken within the last year! I wonder if DCR will now take them down just to appear to be accurate.)

Secondly, we now fall into the trap of the high-tech solution. Not every driver with a tall truck or a bus will have a GPS. (Or, this being Boston, the students' moving vans every September and June.) As you note, "Now its a question of ensuring wide-scale implementation." Why do that when a simple low-tech solution has been proven to work?

Anonymous said...

Boston's signage sucks for an outsider - approaching some intersections there is just a blizzard of signs and you can't speed read them fast enough to absorb them. And, I have been on many buses (for tours) where the driver has no clue where he's going and passengers help him!! Kind of scary.

Sandy said...

You're entirely right about the systemic problem.

I was thinking the same last night as I came down Memorial Drive near MIT where one of the signs says "too low-backup," which isn't very helpful.

Joyce said...

@SJ, I didn't hear the NPR segment you mention, but if the DCR spokesperson said the bells were taken down in 1990, that's entirely inaccurate. It sounds like the remarks of an agency caught in an embarrassing situation. I was a planning student at MIT in the late 1990s. After hearing Bill Geary talk about the cowbells on the Memorial Drive underpasses, I went out to take a look at them. The sight of those cowbells would make me chuckle every time I took a run along Mem Drive, well past when I graduated in 2001. And, I've seen them on more recent walks through the city, as I've taken visiting friends and family on tours and talked about the bells.

His story was a powerful example of a good government leader. Clearly, the DCR has lost its way. I would have hoped for better.

Boston Driver said...

Unless the bus itself knocked off the hanging rubber sign, it appears likely that DCR failed to replaace it in a timely manner; i.e. it didn't maintain the road properly. That doesn't remove the driver's responsibility to ensure the safe passage of his bus, but it does mitigate his culpability here. For high-tech solutions, a flashing sign near low overpasses triggered by a tall-vehicle detector might be useful. It would sure be MUCH cheaper than any scheme to raise the bridges or lower the roadways.

Anonymous said...

Paul, you don't have to use a cell phone while driving to report a missing sign.

You can remember where it is, and call or email at the next safe opportunity.

These signs do get knocked down. The DCR can't inspect every sign every day. But responsible citizens can.

Paul Levy said...

DCR has vehicles along those roads every day, as do state police.

Charles Burlile said...

For those who recall their Psych 101, the area of Stimulus Control in Behavioral Psychology would absolutely predict that just placing a "sign" in a road is no guarantee that drivers will perceive it. Only by experimenting with lots of signs and sign types to find the most effective design could we be confident that the Public's safety was being protected.

Thanks to Mr. Levy for advancing the analysis of this decades-old public policy disaster.

Anonymous said...

Ultimately, there's no "them" -- there's only "us".

If everyone, including you, says "not my problem", that's how things don't get fixed.

Paul Levy said...

I've been reporting things for years, thanks....

Carl said...

I lived at 314 Memorial Drive as a freshman, right next to the Mass Ave underpass, and I remember well the crunching and the peeling back of the tops of vans, usually young couples with a rental truck. We frequently had the shaken drivers in the house to get warm and to start recovering from the shock. I also remember a truck full of eggs that lost its top – without hurting a single egg!

I am sorry to confess that I witnessed many more accidents when my office in Building 1 overlooked the other end of the underpass – and I wish I had thought of the rubber signs back in 1964 after the 9th or 10th such incident!