Chain of errors led to bus death
If only the driver hadn't been a substitute ... a computer had worked right ... or a phone talk had been clear ...
By THOMAS C. TOBIN
Published February 15, 2005
LARGO - A shortage of bus drivers, a computer glitch and a phone miscommunication were among the "horrible set of mistakes" that led to the death of 8-year-old Brooke Ashlee Ingoldsby after she got off a Pinellas school bus, school superintendent Clayton Wilcox said Monday.
Overlooked in the bus system's struggle to keep up with demand was one important notation: "wside," meaning west side.
Had substitute bus driver William A. Ralston known that Brooke was usually dropped off on the west side of Dr. Martin Luther King Jr. Street - not the east side - "it would have been a very different situation," Wilcox said at a news conference.
The notation was clear on the instructions Ralston should have received Friday when he embarked on Route 466 serving James B. Sanderlin and Lakewood elementaries in St. Petersburg. But the instructions he got were incomplete, and later efforts to correct them by phone fell short.
As a dispatcher dictated route information, Ralston wrote down the location of Brooke's stop, 90th Avenue N and King Street, but made no note that she should be dropped off on the west side.
The reason, Wilcox speculated, may have been Ralston's struggling to hear over the noise of children on the bus.
These and other events led to a fateful few moments shortly before 5 p.m. Friday:
Ralston arriving at 90th Avenue N and the east side of King Street with Brooke the last child on his bus; Ralston asking the girl if this was her stop; Brooke, who had been taking the bus only two weeks, saying it was; Ralston watching her walk south in front of his bus, then unable to stop the horror as she tried to cross the five-lane road at rush hour.
The 75-year-old driver tried to open his window and yell at Brooke to stop. But it was too late, Wilcox said. Instead, he told a dispatcher to call 911.
"The tragedy in all of this is that she didn't say, or the bus driver didn't know, to pull across the street," Wilcox said. "If he pulled across the street, this young girl would not have perished."
The superintendent's timeline also revealed another disturbing fact: Brooke endured a two-hour bus ride from Sanderlin, which is just 10 miles from her home. Her bus ride under normal conditions was about an hour.
Her visitation is today.
"The driver is really struggling with the chain of events and feels a great deal of personal remorse but also responsibility," Wilcox said. Neither Ralston nor the other transportation employees who fed him the incorrect information will be disciplined, he said.
Wilcox praised Ralston several times, saying that at every juncture he displayed good instincts.
"It's easy for us in hindsight to say what should have happened," he said. "I just don't think in this case that that would serve us well."
Although the school district is still working to correct the computer glitch that led to Ralston's getting incomplete route instructions, Wilcox said efforts are being made to manually ensure route instructions are given correctly.
Asked whether the families of 40,000 children who receive bus rides should feel safe, he responded: "I absolutely think that we can correct these problems.... But I would also say to parents ... that there are some circumstances in life that we can't as a school system predict or prevent. We will do our very best. Our people will move heaven and earth to protect our kids."
The superintendent laid out a timeline that began with Brooke's regular bus driver recently asking to work another route and being granted his request.
That meant 466 became one of 50 routes in Pinellas now listed as "open" because of a clause in the drivers' union contract that allows others to bid for available routes.
Until a permanent driver is found, the route is staffed by substitutes. Wednesday, a substitute got the correct route instructions and drove it without incident.
On Thursday, the previous driver for 466 filled in and had no problems.
On Friday, Ralston finished driving a field trip to Sunken Gardens, returned to the main bus compound in Largo and got instructions to go to Sanderlin and Lakewood elementaries.
He was given a sheet that listed four bus stops. It should have had 13. The district's software, designed by a company called Education Logistics, has been buggy recently.
The system was sporadically spitting out old route information - a problem in a system where 30 percent of the students are changing schools at any given time, requiring route changes.
Wilcox said he did not know whether the problem was with the system or with the district not using it properly.
On Wednesday, when the other substitute drove Route 466, it gave out the correct information. No one had any reason to think it would give incorrect information on that route on Friday, Wilcox said.
Ralston discovered the problem when he got through the four routes on his sheet and still had a bus full of kids.
The driver pulled over and called a dispatcher, who tried and failed to reach the regular driver. The dispatcher then retrieved an accurate copy of the bus route from a colleague's notebook.
Ralston took about 15 minutes to write down the information. He then got his bearings and started the route again. During the delay, Ralston said, he had to ask the children on the bus several times to quiet down so he could hear the dispatcher.
The bus ride included two other delays: a mistaken turn onto I-275, and a brief stop to help an asthmatic child displaying signs of distress. Together, they added about 10 minutes.
By the time Brooke was dropped off, the picture emerges of a difficult shift for the driver: a one-hour route turned into two, a glitch not of his making, a bus full of noisy children.
But Wilcox said he had no indication Ralston was stressed or hurried.
Juliece Williams, 10, provided another view Monday. She said she got off Ralston's bus at 88th Avenue N and Seventh Street, one stop before Brooke's.
"I tried to tell him where the bus stops were, but he told me to "shut up and sit down," the fourth-grader said.
Ralston of Pinellas Park could not be reached Monday.
Asked whether Ralston's age, 75, was a factor, Wilcox said, "I don't see that at all."
He said the driver recently had gone through a dexterity test and a physical.
There are relatively few drivers as old as Ralston in Pinellas County. On a roster of 790 bus drivers, 58 drivers are 65 or older. Of them, 16 are over 70. The numbers are similar in Pasco and Hillsborough counties.
The district's move to the choice plan last school year means the system needs 800 drivers, as opposed to 500 previously.
As the district struggles to find drivers, Wilcox said recruiters frequently turn to senior centers. The job pays just over $11 an hour plus benefits.
With 50 "open" routes and routine absences, the system is under severe strain, Wilcox said. He said the district would be asking the drivers' union for changes in the contract that would give supervisors the ability to fill routes faster.
--Times staff writers Matthew Waite, Donna Winchester and Lauren Bayne Anderson contributed to this report.
[Last modified February 15, 2005, 06:55:24]
[an error occurred while processing this directive]