Skip Ribbon Commands
Skip to main content
Safety Recommendation Details

Safety Recommendation H-02-023
Details
Synopsis: About 2:15 p.m., central daylight time, on May 1, 2001, a northbound tractor, in combination with a semitrailer that had horizontally mounted cylinders filled with compressed hydrogen, which is a flammable gas, struck a northbound pickup truck that had veered in front of the tractor-semitrailer on U.S. Highway 75, 2 miles south of Ramona, Oklahoma. According to witnesses, the tractor-semitrailer then went out of control and overturned while continuing along the highway. It went off the road to the east and traveled 300 more feet before it stopped. During the process, some of the cylinders, valves, piping, and fittings at the rear of the semitrailer were damaged and released hydrogen. The hydrogen ignited and burned the rear of the semitrailer. In the meantime, the pickup truck had also run off road. The pickup truck's fuel line ruptured, resulting in the truck being destroyed by fire.
Recommendation: TO THE PIPELINE AND HAZARDOUS MATERIALS ADMINISTRATION (ORIGINALLY ISSUED TO RSPA): Modify 49 Code of Federal Regulations 173.301 to clearly require that valves, piping, and fittings for cylinders that are horizontally mounted and used to transport hazardous materials are protected from multidirectional forces that are likely to occur during accidents, including rollovers.
Original recommendation transmittal letter: PDF
Overall Status: Closed - Acceptable Action
Mode: Highway
Location: RAMONA, OK, United States
Is Reiterated: No
Is Hazmat: No
Is NPRM: No
Accident #: DCA01MZ001
Accident Reports: ​Release and Ignition of Hydrogen Following the Collision Between a Tractor/Semitrailer with Horizontally Mounted Cylinders and a Pickup Truck
Report #: HZM-02-02
Accident Date: 5/1/2001
Issue Date: 9/26/2002
Date Closed: 4/27/2010
Addressee(s) and Addressee Status: RSPA (Closed - Acceptable Action)
Keyword(s): Hazmat

Safety Recommendation History
From: NTSB
To: RSPA
Date: 4/27/2010
Response: Because PHMSA, in its final rule dated April 9, 2009, effective May 11, 2009, incorporated the requirements of the Compressed Gas Association’s (CGA) Technical Bulletin 25 (TB-25), Design Considerations for Tube Trailers, into the hazardous materials regulations at 49 CFR 173.301 as requested, Safety Recommendation H-02-23 is classified CLOSED -- ACCEPTABLE ACTION.

From: NTSB
To: RSPA
Date: 4/2/2010
Response: The NTSB is currently reviewing the action taken by PHMSA on the above recommendations, identified in your letter, and expects to have a more substantive response back to you shortly. We apologize for the delay in responding regarding some of the recommendations; however, additional documentation was needed for these before their evaluation for closure could be completed. Action on Safety Recommendation R-89-53 (see enclosure) was completed on March 19, 2010.

From: RSPA
To: NTSB
Date: 3/15/2010
Response: Letter Mail Controlled 3/16/2010 1:16:29 PM MC# 2100096: - From Cynthia L. Quarterman, Administrator: I greatly appreciated meeting with you last month concerning the National Transportation Safety Board's (NTSB) recommendations to the Pipeline and Hazardous Materials Safety Administration (PHMSA). I look forward to meeting with you again, along with staff, on Tuesday, March 16th. Your recommendations, based on lessons learned from accident investigations, provide valuable safety information to our programs. We are committed toconsidering each of the recommendations and implementing those that are positive improvements in safety. I have been meeting with PHMSA's hazmat and pipeline safety programs to assess our actions on the NTSB recommendations. We are addressing these safety issues by taking actions to assure that the "unacceptable actions" are moved into the "open-acceptable" category and to achieve a "closed-acceptable" in a timely manner on as many recommendations as possible. I recognize that a number of "open-acceptable" recommendations are works in progress and maytake a year or more to complete. You indicated your interest in getting these issues resolved as well. As you requested, I asked our pipeline and hazmat staff to compile a copy of outstanding letters to the NTSB that request a change in the classification of a recommendation. I have attached a copy of those letters and am hopeful you and I can successfully resolve a number of these issues. In addition, I have askedour Chief Safety Officer, Cindy Douglass, and our Associate Administrators, Jeff Wiese for Pipeline Safety and Magdy El-Sibaie for Hazardous Materials Safety, to meet with your staff to help us better understand each recommendation and to clarify the actions the NTSB considers necessary for closure. Again, I look forward to meeting with you on these safety concerns and believe that, together, we will make a positive difference in the safe transportation of hazardous materials, including those transported by pipelines.

From: RSPA
To: NTSB
Date: 5/19/2009
Response: Letter Mail Controlled 6/2/2009 1:14:32 PM MC# 2090341: - From Cynthia Douglass, Acting Deputy Administrator: On April 9,2009, PHMSA issued a final rule under Docket Number HM-2 18E entitled Hazardous Materials: Miscellaneous Cargo Tank Motor Vehicle and Cylinder Issues; Petitions for Rulemaking (74 FR 16135; copy enclosed). This final rule amends the Hazardous Materials Regulations (HMR; 49 CFR Parts 17 1-1 80) to require cylinders mounted on motor vehicles or in frames, commonly referred to as tube trailers, to conform to the revised Compressed Gas Association technical bulletin, CGA TB-25 Design Considerations for Tube Trailers, 2008 edition. The revised CGA consensus standard addresses protective structures for valves and pressure relief devices, and design considerations for the static, dynamic, and thermal loads affecting tube trailers. These design considerations are intended to reduce the likelihood of the tube separating from the trailer and to minimize the unintentional release of hazardous materials in the event of a highway collision, including but not limited to, a rollover accident. In the HM-218E final rule, we noted that CGA had formed a committee to address the issues identified by NTSB in its investigation of the Ramona accident. During its analysis of the causal factors of the Ramona accident, CGA observed that the threads on the mounting flange and the corresponding threads on the neck of the failed tube showed evidence of excessive wear. The task force concluded, therefore, that the excessive wear of the threads in the mounting flanges allowed the neck on the rear end of one of the cylinders to pull loose from the mounting flange during the initial rollover. The cantilevered movement of the now unrestrained rear end of the cylinder imparted substantial stress on the restrained front neck of the cylinder, causing the cylinder neck to fracture. CGA noted that its conclusion that contact of the cylinder with the roadway was not the cause of the cylinder failure is substantiated by evidence from previous rollover incidents where cylinders contacting the road surface exhibited only abrasion damage similar to that depicted on the remaining cylinders on the tube trailer shown in Figure 5 of the NTSB investigation report. To address this securement issue, CGA established a task force to develop inspection criteria for the mounting threads on cylinders mounted on tube trailers. The CGA publication on mounting thread inspection is targeted for publication in 2009. In the interim, we have posted periodic thread inspection guidelines for cylinders mounted on tube trailers on the PHMSA website at www.phmsa.dot.gov/staticfiles/PHMSA/DownloadableFiles/Filesfinspection-Procedure.pdf. Based on the actions outlined above, we request that Safety Recommendations H-02-23 and H-02-24 be classified as Closed - Acceptable Action. We appreciate your consideration of this request.

From: NTSB
To: RSPA
Date: 9/4/2008
Response: The Safety Board notes that PHMSA published an NPRM on April 12, 2007, proposing to incorporate the requirements of the Compressed Gas Association’s Technical Bulletin (TB) 25, "Design Considerations for Tube Trailers," into the hazardous materials regulations. The TB defines damage protection standards for all valves, pressure relief devices, and other piping components in contact with the lading and establishes that protective devices or the housing for these components must be able to withstand multidirectional static loads resulting from front, rear, side, or sideswipe collisions, or the overturn of the vehicle. PHMSA currently expects to publish the final rule by the end of 2008. Accordingly, Safety Recommendation H-02-23 remains classified OPEN -- ACCEPTABLE RESPONSE pending the Board’s notification of the final rule being published.

From: RSPA
To: NTSB
Date: 7/31/2007
Response: Letter Mail Controlled 8/8/2007 2:24:08 PM MC# 2070395: - From Stacey L. Gerard, Assistant Administrator/ Chief Safety Officer: In a notice of proposed rulemaking published April 12, we proposed to incorporate the requirements of the Compressed Gas Association Technical Bulletin 25 (TB-25 Design Considerations for Tube Trailers) into the HMR. TB-25 defines basic design considerations for tube trailers to maintain structural integrity during handling and transport. Designs must be able to withstand static, dynamic, and thermal loads found during handling and transport. Designs must address the mounting of individual tubes in tube bundles; attachment of tube bundles to the motor vehicle chassis; and accident damage protection for pressure retaining equipment. We expect to publish a final rule by early 2008.

From: NTSB
To: RSPA
Date: 6/7/2007
Response: MC# 2070157 Response to Notice of Proposed Rulemaking (to PHMSA Docket) The National Transportation Safety Board has reviewed the Pipeline and Hazardous Materials Safety Administration’s (PHMSA’s) notice of proposed rulemaking (NPRM), “Miscellaneous Cargo Tank Motor Vehicle and Cylinder Issues; Petitions for Rulemaking,” Docket No. PHMSA-2006-25910, that was published at 72 Federal Register 18446 on April 12, 2007. The Safety Board notes that the NPRM, in part, addresses Safety Recommendations H-02-23 and -24. On May 1, 2001, a northbound tractor, in combination with a semitrailer that had horizontally mounted cylinders filled with compressed hydrogen, which is a flammable gas, struck a northbound pickup truck that had veered in front of the tractor-semitrailer on U.S. Highway 75, 2 miles south of Ramona, Oklahoma. The tractor-semitrailer then went out of control and overturned while continuing along the highway. It went off the road to the east and traveled 300 feet before it stopped. Some of the cylinders, valves, piping, and fittings at the rear of the semitrailer were damaged and released hydrogen. The hydrogen ignited and burned the rear of the semitrailer. As a result of the accident, the truckdriver was killed, and the driver of the pickup truck was seriously injured. Residents of five homes in the vicinity of the accident were asked to evacuate, and the highway was closed for more than 12 hours. Damage, cleanup, and lost revenues were estimated at $155,000. As a result of its investigation of the Ramona accident (Hazardous Materials Accident Report NTSB/HZM-02/02) the Safety Board recommended that the Pipeline and Hazardous Materials Safety Administration: H-02-23 Modify 49 Code of Federal Regulations 173.301 to clearly require that valves, piping, and fittings for cylinders that are horizontally mounted and used to transport hazardous materials are protected from multidirectional forces that are likely to occur during accidents, including rollovers. H-02-24 Require that cylinders that transport hazardous materials and are horizontally mounted on a semitrailer be protected from impact with the roadway or terrain to reduce the likelihood of their being fractured and ejected during a rollover accident. Safety Recommendations H-02-23 and -24 are currently classified “Open—Acceptable Response.” To address these recommendations, PHMSA is proposing in the NPRM to require under 49 Code of Federal Regulations 173.301 that the transportation of horizontally mounted pressure cylinders on a motor vehicle must comply with the structural integrity standards of the Compressed Gas Association Technical Bulletin 25 (CGA TB-25), Design Considerations for Tube Trailers. PHMSA noted in the NPRM that the Compressed Gas Association developed this technical bulletin to address the Safety Board’s concerns related to the Ramona accident. The Safety Board has reviewed the technical bulletin and notes that the bulletin sets forth damage protection standards for all valves, pressure relief devices, and other piping components “in direct communication” (in contact) with the lading. In the technical bulletin, protective devices or the housing for these components must be able to withstand multidirectional static loads resulting from front, rear, side or sideswipe collisions, or the overturn of the vehicle. The establishment and implementation of such multidirectional static loading standards is responsive to Safety Recommendation H-02-23. The technical bulletin also establishes multidirectional static loading standards for individual cylinders, bundles of cylinders, and the mounting attachments to a truck trailer chassis. While establishment of multidirectional loading standards for the cylinders and mounting attachments is beneficial, the Safety Board does not believe that these standards adequately address Safety Recommendation H-02-24. In the Ramona accident, 6 of the 10 cylinders on the accident semitrailer extended beyond the envelope of the mounting bulkheads on the semitrailer. Consequently, during the rollover and sliding of the semitrailer along the ground, the exposed cylinders, rather than the mounting bulkheads, sustained the initial impact with the roadway and ground. The technical bulletin does not specifically require that the individual cylinders be within the envelope of the mounting bulkheads or otherwise be protected from direct impact with the roadway or ground; nor does the NPRM explain how the implementation of the multidirectional loading standards for the cylinders and mounting attachments reduces the exposure of the cylinders to direct impacts in rollover accidents. The Safety Board believes that the NPRM and the technical bulletin can be improved by addressing this concern. The Safety Board also notes that the technical bulletin defines a “tube module” as an assembly of one or more tubes horizontally mounted with a structural frame and designed to be temporarily mounted on a motor vehicle for transportation. (The cylinders on the tube trailer in the Ramona accident were permanently mounted on the trailer chassis.) However, the technical bulletin does not specifically state that tube modules are to meet the comparable loading and accident protection standards that are being implemented for tube bundles, which are permanently mounted on a trailer chassis. The Safety Board believes that the technical bulletin also should include specific standards for tube modules. The Safety Board appreciates the opportunity to comment on this proposed rulemaking. If additional clarification or information is needed concerning our comments, feel free to contact us. Notation 7371B: The National Transportation Safety Board has reviewed the Pipeline and Hazardous Materials Safety Administration’s (PHMSA’s) notice of proposed rulemaking (NPRM), “Miscellaneous Cargo Tank Motor Vehicle and Cylinder Issues; Petitions for Rulemaking,” Docket No. PHMSA-2006-25910, that was published at 72 FR 18446 on April 12, 2007. The Safety Board notes that the NPRM, in part, addresses Safety Recommendations H-02-23 and 24. On May 1, 2001, a northbound tractor, in combination with a semitrailer that had horizontally mounted cylinders filled with compressed hydrogen, which is a flammable gas, struck a northbound pickup truck that had veered in front of the tractor-semitrailer on U.S. Highway 75, 2 miles south of Ramona, Oklahoma. The tractor-semitrailer then went out of control and overturned while continuing along the highway. It went off the road to the east and traveled 300 feet before it stopped. Some of the cylinders, valves, piping, and fittings at the rear of the semitrailer were damaged and released hydrogen. The hydrogen ignited and burned the rear of the semitrailer. As a result of the accident, the truckdriver was killed, and the driver of the pickup truck was seriously injured. Residents of five homes in the vicinity of the accident were asked to evacuate, and the highway was closed for more than 12 hours. Damage, cleanup, and lost revenues were estimated at $155,000. As a result of its investigation of the Ramona accident, the Safety Board recommended that the Pipeline and Hazardous Materials Safety Administration: H-02-23 Modify 49 Code of Federal Regulations 173.301 to clearly require that valves, piping, and fittings for cylinders that are horizontally mounted and used to transport hazardous materials are protected from multidirectional forces that are likely to occur during accidents, including rollovers. H-02-24 Require that cylinders that transport hazardous materials and are horizontally mounted on a semitrailer be protected from impact with the roadway or terrain to reduce the likelihood of their being fractured and ejected during a rollover accident. Safety Recommendations H-02-23 and -24 are currently classified “Open–Acceptable Response.” To address these recommendations, PHMSA is proposing in the NPRM to require under 49 CFR 173.301 that the transportation of horizontally mounted pressure cylinders on a motor vehicle must comply with the structural integrity standards of the Compressed Gas Association, Incorporated Technical Bulletin 25 (CGA TB-25), Design Considerations for Tube Trailers. PHMSA noted in the NPRM that the Compressed Gas Association developed this technical bulletin to address the Safety Board’s concerns related to the Ramona accident. The Safety Board has reviewed the technical bulletin and notes that the bulletin sets forth damage protection standards for all valves, pressure relief devices, and other piping components “in direct communication” (in contact) with the lading. In the technical bulletin, protective devices or the housing for these components must be able to withstand multidirectional static loads resulting from front, rear, side or sideswipe collisions, or the overturn of the vehicle. The establishment and implementation of such multidirectional static loading standards is responsive to Safety Recommendation H-02-23. The technical bulletin also establishes multidirectional static loading standards for individual cylinders, bundles of cylinders, and the mounting attachments to a truck trailer chassis. While establishment of multidirectional loading standards for the cylinders and mounting attachments is beneficial, the Safety Board does not believe that these standards adequately address Safety Recommendation H-02-24. In the Ramona accident, six of the ten cylinders on the accident semitrailer extended beyond the envelope of the mounting bulkheads on the semitrailer. Consequently, during the rollover and sliding of the semitrailer along the ground, the exposed cylinders, rather than the mounting bulkheads, sustained the initial impact with the roadway and ground. The technical bulletin does not specifically require that the individual cylinders be within the envelope of the mounting bulkheads or otherwise be protected from direct impact with the roadway or ground; nor does the NPRM explain how the implementation of the multidirectional loading standards for the cylinders and mounting attachments reduces the exposure of the cylinders to direct impacts in rollover accidents. The Safety Board believes that the NPRM and the technical bulletin can be improved by addressing this concern. The Safety Board also notes that the technical bulletin defines a “tube module” as an assembly of one or more tubes horizontally mounted with a structural frame and designed to be temporarily mounted on a motor vehicle for transportation. (The cylinders on the tube trailer in the Ramona accident were permanently mounted on the trailer chassis.) However, the technical bulletin does not specifically state that tube modules are to meet the comparable loading and accident protection standards that are being implemented for tube bundles, which are permanently mounted on a trailer chassis. The Safety Board believes that the technical bulletin also should include specific standards for tube modules. The Safety Board appreciates the opportunity to comment on this proposed rulemaking. If additional clarification or information is needed concerning our comments, feel free to contact us.

From: RSPA
To: NTSB
Date: 4/14/2006
Response: PHMSA, in cooperation with FMCSA and industry, is reviewing the appropriate actions to address this recommendation. The Compressed Gas Association (CGA) completed its research and PHMSA reviewed and provided comments. The proposed changes were addressed at the October 2005 CGA meeting. CGA accepted PHMSA's comments. PHMSA continues to evaluate the CGA Technical Bulletin for possible incorporataion into the HMR.

From: RSPA
To: NTSB
Date: 2/28/2005
Response: In its 2/28/2005 report to Congress, "Open Statutory Mandates Regarding Pipeline and Hazardous Materials Safety," the DOT wrote: RSPA, in cooperation with FMCSA and industry, is reviewing actions to address this recommendation. NTSB views the work required to be a multi-year effort.

From: NTSB
To: RSPA
Date: 5/6/2003
Response: The Safety Board notes that RSPA agrees with the intent of these recommendations. The Board also notes that RSPA met with the Federal Motor Carrier Safety Administration (FMCSA) and the Compressed Gas Association (CGA) in an effort to consult and cooperate with these organizations in addressing the recommendations. The Board recognizes that as a result of these meetings, the CGA has established a special task force under their Docket 02-19, "Development of Performance Standards for Tube Trailers," and the FMCSA is considering an appropriate expansion of its enforcement program to include tube-trailer manufacturers and assemblers. RSPA indicates that it views the work required to address Safety Recommendations H-02-23 through -25 as a multi-year effort, culminating in rulemaking, and that it is committed to continuing its consultation and cooperation with the FMCSA and the CGA to fully satisfy these safety recommendations. The Safety Board commends RSPA for its dedication to improving the safety of horizontally mounted tube cylinders that transport hazardous materials. Pending notice that this task has been completed, Safety Recommendations H-02-23 through -25 are classified OPEN -- ACCEPTABLE RESPONSE.

From: RSPA
To: NTSB
Date: 1/6/2003
Response: Letter Mail Controlled 01/22/2003 5:18:20 PM MC# 2030054 - From Ellen G. Engleman, Administrator: RSPA agrees with the thrust of your recommendations. Prior to the issuance of your letter and final report we took proactive measures to contact both the Federal Motor Carrier Safety Administration (FMCSA) and the Compressed Gas Association (CGA) to discuss possible action plans and tasks to address the issues surrounding the incident. As a result of those discussions, CGA has established a special task force under their Docket 02- 19, Development of Performance Standards for Tube Trailers. Their work will be monitored and reviewed for possible incorporation in the Hazardous Materials Regulations. We also understand that FMCSA is considering appropriate expansion of its enforcement program to include tube trailer manufacturers and assemblers. The changes suggested to the North American Emergency Response Guidebook (NAERG) will be considered for inclusion in the 2004 Edition. We recognize that the work required to address the concerns of the NTSB will require a multi-year effort, culminating in rulemaking. We are committed to continuing our consultation and cooperation as we resolve the issues identified in these safety recommendations, and will keep your informed of our progress. We request that you classify recommendations H-02-23 through H-02-25 as "Open-Acceptable Action."