The sheriff's report said Mr. Robles was negligent for not having a valid Texas driver's license. State law allows people to drive on a Mexican license for 30 days. Mr. Robles had been in the U.S. for seven months.
That prevented state officials from assessing his driving skills because Mr. Robles would have had to pass a written exam and road test to get a Texas license, the report said.
The report also faulted Mr. Robles for driving 15 hours nonstop and for not speaking English. Federal regulations say bus drivers must be able to read road signs, fill out their logbook, talk to police and converse with the public.
Mr. Robles was only able to communicate with the lead caretaker on the bus, Bonnie Estes, who spoke Spanish but was not fluent, nursing home staff told the NTSB.
THE LAST MOMENTS
More harrowing details of the worst Texas bus accident in half a century were revealed in witness statements, crime scene photographs and reports released recently by the Dallas County Sheriff's Department.
BEFORE THE BLAST: With plans to be gone just a few days, the passengers had small suitcases and duffel bags. Many patients stuffed some clothes in plastic bags. The nursing home had food a case of ready-to-eat meals and Aquafina water bottles.
FRAIL PASSENGERS: An inventory of the cargo compartments attests to their vulnerability: 22 wheelchairs, four walkers and three cases of large blue diapers.
FINDING THE FIRE: A passing pickup stopped in front of the bus to warn of the fire. The driver, Juan Robles Gutierrez, got out and swatted at the flames with his shirt. Despite their caregivers' pleas to escape, many patients refused to get up.
HELP ARRIVES: Passers-by frantically tried to break windows. Sheriff's Department Sgt. Patrick Fassett shined his flashlight through the thick smoke. "I could hear several people yelling for help, but I couldn't see them," he later said. Deputy Scott Evans ran to the driver's side for another way in. "I could hear the fire crackling and the windows popping," he said.
THE FINAL TOLL: The blast of the oxygen canisters blew Sgt. Fassett out of the bus and knocked Deputy Evans to the ground. Twenty-three patients died, some of them still in their seats, hands on the armrests, heads against the cushions.