WASHINGTON A punctured tire caused the bus crash near Sherman, Texas, that killed 17 Houstonians heading to a church retreat last year, the National Transportation Safety Board said Tuesday. But investigators uncovered many other startling problems with the bus company, the driver and the safety inspections that allowed the bus to stay on the road.

The driver had used cocaine and alcohol just before pulling out of Houston that night with 55 Vietnamese-American passengers, investigators said.

The bus company had evaded an order to stay off the road by reregistering under a new name, and was operating without a permit or insurance. The Houston garage that inspected the bus a week earlier didn't spot an illegal retread tire on the front axle, wasn't equipped to inspect heavy vehicles, and received only perfunctory oversight by Texas authorities.

And an alphabet soup of federal agencies had ignored years of warnings that buses should be equipped with seatbelts, luggage racks that don't fall apart during a crash, and other upgrades.

"This was just a perfect storm of gross negligence," Yen-Chi Le, a Galveston, Texas, psychologist whose mother was among those killed, said near the end of the four-hour safety board meeting.

The tragedy just after midnight on Aug. 8, 2008, was one of the worst ever on Texas roads, but safety board chairwoman Deborah Hersman said that in some ways, it was all too reminiscent of wrecks the board has investigated for decades.

"We have not seen one iota of change with respect to crashworthiness for motor coaches," she said. "It feels like we're pounding our heads against the wall."

The bus carried 55 Vietnamese-Americans from Houston heading to a Catholic retreat in Carthage, Mo. Four-and-a-half hours into the trip, the right front tire, which had had a new tread applied, blew out. Investigators said the puncture could have occurred early in the 309-mile trip from Houston or, more likely, within a few days beforehand.

The driver wouldn't have known the tire was underinflated by looking at it. Yet pressure gauges aren't required for pre-trip inspections, and older buses aren't equipped with automatic warning systems used in new cars prompting recommendations Tuesday on both fronts from the safety board, which investigates crashes but lacks enforcement power.

The bus struck a curb, crashed through a guardrail and fell 8 feet, landing on its side and sliding 24 feet. The bus had been going 68 mph. In addition to the deaths, 38 passengers and the driver were hurt.

Investigators revealed Tuesday that, based on a urine sample taken four hours after the crash, the driver had used cocaine and alcohol five or six hours before the crash that is, shortly before leaving Houston that night.

Although the driver, Barrett Broussard, apparently made no maneuvers that caused or worsened the crash, Le called the drug use "really awful" and was upset he hasn't faced criminal charges.

Investigators also revealed Tuesday that the driver had been fired in 1995 by Greyhound after a drug test showed cocaine use a fact that apparently was unknown to his current employer because he hadn't listed Greyhound as a previous employer on his job application.

The Sherman crash also vividly illustrated the problem of so-called "chameleon carriers" companies that regulators shut down for safety reasons but emerge with new names to continue operating.

The bus was owned by a company called Iguala BusMex, but that was only its latest incarnation. The company had started in 1994 as Angel Tours.

On May 1, 2008, the Federal Motor Carrier Safety Administration, which regulates interstate buses, gave Angel Tours an unsatisfactory rating, citing a number of critical violations. After 45 days, the company lost its interstate permit, though it continued to operate interstate trips anyway.

On July 27, two weeks before the Sherman crash, a company calling itself Iguala BusMex applied for a permit, listing the same address and phone number as Angel Tours. It was, in fact, the same company, investigators said.

Iguala BusMex was still awaiting a permit and insurance when it undertook the Houston-Missouri church trip.



Hersman lauded the bus agency for trying to keep the carrier off the road but said regulators "just weren't able to tighten the sieve enough."

It's a widespread problem. In July, the Government Accountability Office reported that in the past two years, nearly 10 percent of interstate bus operators that lost federal permits on safety grounds 20 out of 220 managed to quickly resume business, typically through unscrupulous registrations.