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"Lessons Learned" is a series of drop-in articles prepared by the NTSB for use 
in publications of other organizations.  An index of articles is available at
http://www.ntsb.gov/events/journalist/lessons/lessons.htm
06/2007
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Lessons Learned from a Motorcoach Tragedy
NTSB Calls for Fire Prevention Upgrades on Motorcoaches 


Its investigation into a bus accident that killed 23 elderly people fleeing Hurricane
Rita has prompted the National Transportation Safety Board to issue a series of far-reaching
recommendations to federal highway regulators to improve motorcoach safety. 

The accident occurred on September 23, 2005. A 1998 Motor Coach Industries, Inc., 54-passenger
motorcoach, operated by Global Limo Inc., of Pharr, Texas, was traveling northbound on 
Interstate 45 near Wilmer, Texas.  The motorcoach, en route from Bellaire to Dallas, Texas, 
as part of the evacuation in anticipation of Hurricane Rita, was carrying 44 assisted living 
facility residents and nursing staff.  A passing motorist alerted the driver that the 
right-rear tire hub was glowing red.  The driver and nursing staff exited the motorcoach and
saw flames coming from the right-rear wheel well.  As they initiated an evacuation, with 
assistance from passersby, heavy smoke and fire quickly engulfed the entire vehicle.  
Twenty-three of the 44 passengers died, two were seriously injured, and 19 received minor 
injuries.  The driver also received minor injuries.

As a result of its investigation, the Safety Board is urging the Federal Motor Carrier Safety 
Administration (FMCSA) to gather and evaluate information on the causes, frequency, and 
severity of bus and motorcoach fires; conduct ongoing analysis of fire data to measure the 
effectiveness of fire prevention and mitigation techniques; and prohibit commercial vehicles 
from operating with wheel seal or other hub lubrication leaks.

Until completion of the Comprehensive Safety Analysis 2010 Initiative, the NTSB also wants 
the FMCSA to immediately issue an interim rule to include all FMCSA regulations in the current 
compliance review process so that they are reflected in the calculation of a carrier’s final 
rating.

The NTSB is also urging the National Highway Traffic Safety Administration (NHTSA) to develop 
detection systems to monitor the temperature of wheel well compartments to provide early 
warning of malfunctions that could lead to fires. Standards for better fire protection of 
motorcoach fuel systems and fire-hardening of exterior fire-prone materials, such as those 
in areas around wheel wells, will limit the potential for flame spread into the passenger 
compartment.

In addition, the Safety Board wants NHTSA to evaluate emergency evacuation designs of 
motorcoaches and buses by conducting simulation studies and evacuation drills, taking into 
account acceptable egress times for postaccident environments, including fire and smoke; 
unavailable exit situations; and the current above-ground height and design of window exits to
be used in emergencies by all potential vehicle occupants.

The accident report and recommendations are available at www.ntsb.gov.