A scathing audit of Baltimore City Public Schools’ pupil transit office said a lack of district leadership and oversight contributed to “an accumulation of errors” that led to a November 2016 bus crash that left six people dead.
“A systemic absence of leadership over an extended period of time is the culprit,” said the audit by School Bus Consultants, a Missouri-based firm.
The company was hired to review the district’s pupil transportation office after the fatal accident. A driver whose company was under contract to the district, Glenn Chappell, 67, had a history of seizures and had been involved in at least 12 crashes over the course of five years.
He was driving an empty school bus in Southwest Baltimore on Nov. 1, 2016, when he crashed into a car and a Maryland Transit Administration bus. Chappell was killed, along with the driver of the other bus and four passengers.
“The school bus involved was being operated under contract to the BCPS who, as an organization, failed to provide the single, cohesive, and robust system that is necessary to prevent an accumulation of errors, or to provide due diligence over the systems that it does have in place,” the audit said.
“It is this primary finding that allowed a school bus driver with a disqualifying medical condition to move from employer to employer, never staying long at any one, but never once being rejected for employment at any employer who was in the business of providing service to the BCPS,” the School Bus Consultants report said. “The accumulation of errors resulting in this tragic incident occurred due to issues within the organization and operations of the Baltimore City Public Schools Office of Pupil Transportation.”
The consulting firm cited vacancies and high turnover in the pupil transit office as limiting its ability to perform critical oversight of contractors — problems that the report, dated Jan. 31, said had not been rectified.
“Even after the tragic events of November 2016,” the audit said, “no apparent changes were made to organizational structure or operating practices to mitigate the risk of a similar subsequent event occurring.”
The audit said the problems go well beyond the transportation office.
“Of particular note at the outset is the absence of any School Board policy or regulation that addresses transportation service,” the audit said. “This is a remarkable and disturbing finding.”
The consultants said the district failed to adequately monitor the records of problem bus drivers such as Chappell.
“The responsible driver in the November 1, 2016 crash, over several years of driving a school bus, continued to deceive all of the BCPS contractors for whom he worked,” the audit said. “The contracted employer and BCPS failed to fully understand his medical conditions or to disqualify him from transporting BCPS students. It is apparent that at several points in time, contracted operators and BCPS simply failed in their duty to find errors in this driver’s documentation.”
The consultants criticized the oversight of contractors, saying there appeared to be no “formal management plan that would tell the district the who, what, when, why and how of the contractors’ operations relative to their contractual requirements.”
The audit cited “a large gap between what is expected of vendors, as documented in contract, and what actually happens operationally... This is an untenable set of circumstances which, when coupled with the absence of a formal compliance monitoring program, can lead directly to lapses in record-keeping, compliance, and associated failures.”
School officials said Friday in a prepared statement that the school system has already made changes that address shortcomings cited in the audit.
“While City Schools has always had a process for monitoring driver certification, immediately after the November 2016 accident, the district reviewed all protocols and implemented additional monitoring steps to ensure the fitness to drive of all drivers, including both those directly employed and those employed by contracted transportation providers,” the statement said.
Spokeswoman Edie House Foster declined to comment beyond the written statement, which also noted that the district has a new director of pupil transportation and that it has revised procedures to “reflect current industry standards.”
Chappell had a history of hypertension, diabetes and seizures, according to the National Transportation Safety Board, conditions that could disqualify a person from operating a commercial motor vehicle under state and federal law. He drove for AAAfordable Transportation, and the school system terminated its contract with the company three weeks after the crash.
The consultants said the district’s use of technology is “deficient and contributes to the circumstances enabling incidents such as occurred in November 1, 2016.”
Bus routing was done using electronic spreadsheets rather than routing software, for example, GPS tracking and video monitoring are not routinely utilized, and accident records are tracked and stored in a combination of paper files and electronic spreadsheets, the audit said.
“Leveraging technology to improve transparency and increase management effectiveness is largely absent in current BCPS transportation operations,” the audit concluded.
According to the district’s statement, “Beginning this summer, the GPS technology already in all buses will be leveraged to allow recording of which students are on which buses at any given time.”