In bold type, a letter from the Maryland Motor Vehicle Administration informed Glenn Chappell in early September that he was "no longer authorized" to drive a school bus and could lose his license unless he provided documentation that a doctor had cleared him to be behind the wheel.
But the state agency didn't inform the Baltimore school system that his driving privileges had been suspended. For 40 school days, Chappell continued to ferry 17 homeless and special-needs students across the city to and from Dallas F. Nicholas Sr. Elementary School.
Then this week, Chappell drove his school bus into a transit bus, killing himself and five other adults. The state did not revoke Chappell's commercial driver's license, which prompted an alert to the school system, until Wednesday — the day after the crash.
That lag in flagging a potential safety risk has raised questions about how closely authorities monitor drivers of school buses and other commercial vehicles despite a labyrinth of laws and regulations aimed at ensuring the safe transport of schoolchildren and other passengers. It was not the first time Chappell's commercial driving privileges had lapsed for lacking proof of good health.
"A day after the accident is too late to be notifying the district that this person shouldn't be driving," said Imani-Angela Rose, director of Joshua's Place Early Learning and Enrichment Center in Northwest Baltimore. "Regardless of whether he had a medical condition or not ... somewhere the ball was dropped."
Police and federal transportation officials are still piecing together what happened in the moments before Chappell, driving a school bus, rear-ended a Ford Mustang, crossed into oncoming traffic and struck a Maryland Transit Administration bus at high speed in Southwest Baltimore on Tuesday. Witnesses said it looked like explosives had torn the buses apart. Crash investigators found no skid marks on the roadway.
Investigators are probing whether Chappell had a medical emergency that led to the crash after ruling out mechanical failure as a factor and finding no reason to suspect that he intentionally caused the crash. In 2014, after Chappell crashed his Buick LeSabre into a guardrail in Ellicott City, his wife told police he was taking medication for seizures.
Chappell's son, Moses, has said his father was a good driver, and Glenn Chappell had a medical examiner's certificate attesting to his health on file at the city school district and with his employer, AAAfordable Transportation Inc., a school bus contractor for the district. Most students in Baltimore take MTA buses to school, but the school district hires companies to transport students with special needs.
School systems across the state pay for continuous monitoring of their bus drivers' records through the Motor Vehicle Administration, or have otherwise devised systems to ensure that students are transported safely. State and federal laws set rigorous standards for bus drivers' health and capability behind the wheel.
But for concerned parents and lawmakers, Chappell's case reveals that the safeguards aren't a guarantee.
Del. William Folden, a police officer who has sponsored legislation on commercial driving, said lawmakers should review the MVA's program for notifying drivers of their license status during the next General Assembly session, which begins in January.
Folden said lawmakers might consider whether the MVA should be required to notify not just the driver, but also the driver's employer, when paperwork is due to expire and driving privileges have been suspended.
"We need to get it resolved if there's something we can do better, so this never happens again," said the Frederick County Republican, who has led a crash investigation team during his law enforcement career.
Since the early 1990s, federal law has required drivers of commercial vehicles, including school buses, to undergo medical examinations to make sure it's safe for them to be on the road. In Maryland, as in most states, state law adopts that federal standard to cover professional motorists who don't cross state lines in their work.
Conditions that could disqualify drivers include hearing or vision loss, epilepsy, narcolepsy, hypertension and diabetes. The requirement was made even more stringent after 22 elderly passengers died in a New Orleans motor coach crash on Mother's Day in 1999.
The standards are similar to those applied to airline pilots, said Duane DeBruyne, a spokesman for the Federal Motor Carrier Safety Administration, which oversees the safeguards. They are intended to ensure that drivers are both physically and mentally equipped for the responsibility their jobs carry.
Since 2014, the administration has required that doctors, physician assistants and nurse practitioners who are specifically trained to examine drivers perform the physical. These medical examiners are listed in a federal registry, and the MVA and its counterparts around the country are required to keep the certificates on file.
The medical examiners can issue certificates that last as long as two years. But if they find medical problems that bear monitoring, they often set expiration dates for a year or less, DeBruyne said.
Chappell twice let those expiration dates pass before providing the MVA with a new certificate.
The agency first warned him that he risked losing his license in May 2015, and he nearly did. His certification expired that July, after which he was not legally permitted to get behind the wheel of any commercial vehicle. In late August, as the MVA was in the process of canceling Chappell's driving privileges, he provided a new one-year certificate.
But a year later, he was again in breach of state requirements for commercial driver's licenses. The MVA asked for a new certificate in letters sent to Chappell in July and September, but agency officials said they never received one.
While Baltimore City schools officials allowed a Baltimore Sun reporter to inspect a certificate showing that Chappell indeed passed a physical in June, that proof was never shared with the MVA, agency spokesman Charles Brown said.
The agency had given Chappell until Oct. 10 to produce a new certificate — more than one month after his old one had lapsed. Brown said that gap was intended to give him "plenty of time" to get his paperwork up to date. In the meantime, his driving privileges were suspended.
The agency did not take the final step of downgrading Chappell's license until Wednesday. The MVA doesn't revoke all driving privileges when commercial drivers fail to provide medical certificates; Chappell could still legally operate his own car.
Despite the back-and-forth between Chappell and the MVA, Baltimore school officials did not learn that his driving credentials were compromised until after he was dead, and after he had illegally operated a school bus for two months.
The MVA does not keep records on the employers of commercial license holders, and only sends the warning letters about expired medical certificates and suspended driving privileges to the address on file for the driver, Brown said. In some cases, drivers put the address of the bus company or school system they work for on MVA forms, but not uniformly, he said.
Instead, school districts must be proactive in ensuring their drivers are healthy and competent.
There are about 188,000 commercial driver's license holders in Maryland, and 27,000 of them have passed the extra knowledge and driving test required for a special endorsement that allows them behind the wheel of a school bus.
In Carroll County, the school system's transportation office staff uses software to keeps tabs on more than 400 drivers who work for 52 bus companies contracted by the county.
Anne Arundel County also keeps track of driver information in a database, and contacts the bus companies any time there's an issue with a driver's license, including the need to update the medical certificate, said Maneka Monk, a school system spokeswoman. It's then up to the company to notify the driver of the issue.
Those school districts and others across the state, including in Baltimore City and Baltimore, Howard and Harford counties, keep tabs on drivers through the MVA alert service. Bus operators and other companies also subscribe to the system.
That MVA system alerts them to changes to a driver's record, including when drivers receive a moving violation, points on their license, or when their licenses are revoked or downgraded to a noncommercial license, Brown said.
Chappell pleaded guilty in 2014 to failing to show a registration card on demand and in 2015 to driving a vehicle with a suspended registration. He also was sued by Howard County over $150 in unpaid traffic tickets stemming from allegedly running red lights in 2014, court records show.
But the expiration of a medical certification doesn't trigger an MVA alert.
The medical certification system also depends on the honesty of drivers.
Though federal transportation safety officials have strengthened the medical certification program in recent years, drivers are taken at their word when asked about past medical concerns. They aren't required to provide medical records. And typically, if a doctor, physician assistant or nurse practitioner finds a driver unfit to drive, the only proof of that is kept in confidential medical records.
The drivers sign the documents certifying they are in good health under penalty of perjury.
Baltimore Sun reporter Liz Bowie contributed to this article.