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Safety Recommendation Details

Safety Recommendation H-07-001
Details
Synopsis: On September 23, 2005, a 1998 Motor Coach Industries, Inc., 54-passenger motorcoach, operated by Global Limo Inc. (Global), of Pharr, Texas, was traveling northbound on Interstate 45 (I-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. The trip had begun about 3:00 p.m. on September 22. Fifteen hours later, about 6:00 a.m. on the following day, a motorist noticed that the right-rear tire hub was glowing red and alerted the motorcoach driver, who stopped in the left traffic lane and then proceeded to the right shoulder of I-45 near milepost 269.5. The driver and nursing staff exited the motorcoach and observed flames emanating from the right-rear wheel well. As they initiated an evacuation of the motorcoach, with assistance from passersby, heavy smoke and fire quickly engulfed the entire vehicle. Twenty-three passengers were fatally injured. Of the 21 passengers who escaped, 2 were seriously injured and 19 received minor injuries; the motorcoach driver also received minor injuries.
Recommendation: TO THE FEDERAL MOTOR CARRIER SAFETY ADMINISTRATION: Establish a process to continuously gather and evaluate information on the causes, frequency, and severity of bus and motorcoach fires and conduct ongoing analysis of fire data to measure the effectiveness of the fire prevention and mitigation techniques identified and instituted as a result of the Volpe National Transportation Systems Center fire safety analysis study.
Original recommendation transmittal letter: PDF
Overall Status: Closed - Acceptable Action
Mode: Highway
Location: Wilmer, TX, United States
Is Reiterated: No
Is Hazmat: No
Is NPRM: No
Accident #: hwy05mh035
Accident Reports: Motorcoach Fire on Interstate 45 During Hurricane Rita Evacuation
Report #: HAR-07-01
Accident Date: 9/23/2005
Issue Date: 6/27/2007
Date Closed: 9/15/2015
Addressee(s) and Addressee Status: FMCSA (Closed - Acceptable Action)
Keyword(s):

Safety Recommendation History
From: NTSB
To: FMCSA
Date: 9/15/2015
Response: We are pleased that you have established, and recently initiated your third iteration of, a process to gather and evaluate the recommended information and conduct ongoing analyses of bus and motorcoach fire data. In addition, we note that, in July 2007, you published regulatory guidance to ensure that reports about commercial vehicle fires would be uploaded into your Motor Carrier Management Information System, improving your data collection. These actions address the intent of Safety Recommendation H-07-1, which is classified CLOSED—ACCEPTABLE ACTION.

From: NTSB
To: FMCSA
Date: 2/13/2014
Response: CC# 201301266- ANPRM Response to Federal Transit Administration: ANPRM - The National Public Transportation Safety Plan, the Public Transportation Agency Safety Plan, and the Public Transportation Safety Certification Training Program; Transit Asset Management: Although the introduction of the ANPRM states that FTA “intends to focus its initial oversight and enforcement efforts on rail transit systems’ implementation of and compliance with these requirements,” the NTSB would like to provide some additional comments with regard to transit bus safety for FTA’s future planning purposes. As was noted in the ANPRM, the NTSB held an investigative hearing on transit bus safety in March 1998, investigated several transit bus accidents, and issued a Special Investigation Report titled Transit Bus Oversight. The report noted that FTA was unable to identify conditions on buses for the traveling public or resolve any unsafe conditions due to a lack of effective safety oversight and enforcement. In addition, the NTSB questioned the utility of the safety data that was being collected on transit bus safety. Finally, the NTSB was concerned that, at the time, a comprehensive bus safety program was not available to transit agencies outside of APTA’s membership program. Based on the findings of the investigation, the NTSB issued the following safety recommendations to the US Department of Transportation: Develop and implement an oversight program to assess and ensure the safety of transit bus operations that receive Federal funding. (H-98-43) Collect accurate, timely, and sufficient data so that thorough assessments can be made relating to transit bus safety. (H-98-44) Evaluate the collected data, as part of the oversight program, to identify the underlying causes of transit bus accidents that could lead to the identification of safety deficiencies at transit agencies. (H-98-45) Develop, in cooperation with the American Public Transit Association, the Community Transportation Association of America, and the American Association of State Highway and Transportation Officials, a model comprehensive safety program(s) and provide it to all transit agencies. (H-98-46) In response, the FTA-sponsored outreach and research efforts to develop a model program for transit bus safety and security. Subsequently, the recommendations were closed with an acceptable response status by the NTSB. Moving forward, however, these recommendations must not be forgotten as data collection and evaluation is an integral component of any safety management program. It is vital that FTA continue to assess and monitor the safety of transit bus operations, including the collection of accurate, timely, and sufficient data so that thorough assessments can be made relating to transit bus safety. Likewise, it is essential that a program be maintained whereas transit bus accidents are thoroughly investigated to identify the underlying causes of crashes so that safety improvements can be implemented in a timely manner. While the NTSB is encouraged that FTA has developed a well-received bus safety program, we are concerned that the program remains completely voluntary and that FTA is unable to ensure that all bus transit agencies are positively affected. In 2013, the safety of bus operations was highlighted as a safety issue area of concern as part of the NTSB’s Most Wanted List. Over the years, the NTSB has made numerous recommendations to the motorcoach and school bus associations, manufacturers, and regulatory agencies such as the Federal Motor Carrier Safety Administration (FMCSA) and the National Highway Traffic Safety Administration (NHTSA), which the NTSB believes should be considered when establishing a robust oversight program for bus transit operations. These recommendations address safety concerns such as driver distraction, driver fatigue, medical oversight, fire safety, event data recorders, and vehicle safety equipment. FTA should refer to the NTSB safety recommendations database for additional information. The following are examples of some of the NTSB recommendations which should be considered. Fire Safety To FMCSA: Establish a process to continuously gather and evaluate information on the causes, frequency, and severity of bus and motorcoach fires and conduct ongoing analysis of fire data to measure the effectiveness of the fire prevention and mitigation techniques identified and instituted as a result of the Volpe National Transportation Systems Center fire safety analysis study. (H-07-1)

From: NTSB
To: FMCSA
Date: 9/30/2010
Response: Notation 8248: The National Transportation Safety Board (NTSB) has reviewed the Federal Motor Carrier Safety Administration’s (FMCSA) Announcement of Public Listening Session and Request for Comment, which was published at 75 Federal Register 53015 on August 30, 2010. The notice announced that the FMCSA planned to hold a public listening session to solicit input on key challenges facing the motor carrier industry, issues facing stakeholders, and concerns that should be considered by the agency in developing its next 5-year Strategic Plan. NTSB staff attended the listening session and provided the FMCSA with a list of open recommendations that have been issued to the FMCSA. The FMCSA also invited written comments, suggestions, and recommendations from all individuals and organizations regarding the FMCSA’s mission, vision, and strategic objectives (goals) for the plan. This letter provides a more detailed history of the currently open recommendations the NTSB has made to the FMCSA (attached), a summary of the key safety issues the FMCSA should address to improve truck and bus safety as presented during the NTSB’s April 28, 2010, testimony before the U.S. Senate Committee on Commerce, Science, and Transportation, Subcommittee on Surface Transportation and Merchant Marine Infrastructure, Safety, and Security (attached), and responds to the questions most relevant to the NTSB’s mission for which the FMCSA is seeking input. Question 2. How can the FMCSA have a greater impact in the reduction of injuries and loss of life on our nation’s highways? The NTSB currently has 51 open recommendations that were issued to the FMCSA with the intent to improve safety on our highways. The implementation of these recommendations would allow the FMCSA to have both an immediate and lasting impact on reducing loss on our highways. We continue to believe that a plan to implement the recommendations on the NTSB’s Federal Most Wanted List of Transportation Safety Improvements (MWL) would significantly contribute to transportation safety. Question 5. How can the FMCSA balance driver-focused, vehicle-focused, motor carrier- focused compliance, interventions, and enforcement to achieve its safety mission? The NTSB has recommended that the FMCSA change the “balance” of its motor carrier oversight since 1999. The two most important factors related to safe motor carrier operations are the condition of the vehicles and the performance of the drivers. Current rules prevent the FMCSA from putting carriers out of service with an unsatisfactory rating in only one of the 6 rated factors. They must be unsatisfactory in at least 2 factors. In other words, they could be unsatisfactory in either the vehicle or driver areas and still be allowed to operate. The NTSB believes that an unsatisfactory in either category should be sufficient cause to place a carrier out of service. The NTSB recommended that the FMCSA do something relatively simple: change the safety fitness rating methodology so that adverse vehicle- or driver performance-based data alone would be sufficient to result in an overall “unsatisfactory” rating for a carrier. To date, the FMCSA has not acted on this recommendation. As a result, the NTSB added this recommendation to our Most Wanted List of Transportation Safety Improvements. The NTSB has been encouraged that the FMCSA is developing the CSA 2010 Initiative to include a greater emphasis on vehicle and driver safety. However, the NTSB is disappointed that the FMCSA did not make the incremental changes to the current safety system necessary to make either driver or vehicle deficiencies sufficient to affect the safety rating of a carrier. As such, the NTSB believes the FMCSA’s strategic plan should recognize the importance of getting carriers with unsafe drivers or unsafe vehicles off the road. Question 8. What technological changes could positively impact highway safety? The NTSB has recommended numerous technological improvements to both the FMCSA and the National Highway Traffic Safety Administration (NHTSA). Two technologies, forward collision warning systems (FCWs) and electronic onboard recording systems (EOBRs), are currently on the NTSB’s Federal MWL. Both of these technologies have been available for the last decade and could have improved highway safety. More recently, the NTSB has recommended to NHTSA technologies for driver fatigue detection, stability control for buses, event data recording, and lane departure warning for buses. The implementation of these recommendations would significantly improve highway safety. Question 9. How will technology affect driver behavior? Well designed technology can improve driver performance. Current research by the FMCSA on vehicle based collision warning systems found improved driver performance as a result of technology. However, technology not designed for use in vehicles, such as cell phones, can distract the driver from the road. That is why the NTSB supported the FMCSA’s ban on texting. Further, the NTSB has included restricting bus drivers from using a cell phone on its Federal MWL. The NTSB appreciates the opportunity to comment on this notice addressing concerns that should be considered in developing the FMCSA’s 5-year Strategic Plan. Many of the issues discussed here have been around for decades, and much is left to be done to improve highway safety. Prompt action is needed so that the trucks and buses that surround us on the nation’s highways are safely designed, maintained, and operated. We look forward to working with FMCSA in the near future to address the concerns presented in these comments.

From: NTSB
To: FMCSA
Date: 9/4/2008
Response: The Safety Board notes that the FMCSA is engaged in several activities concerning the collection and analysis of fire data in an effort to enhance the safety of commercial motor vehicles (CMV). Prior to the adoption of the Board’s report, the FMCSA entered into an agreement with the U.S. Department of Transportation’s Volpe National Transportation Systems Center (Volpe) to conduct a motorcoach fire safety analysis study, with the primary objective of gathering and analyzing information regarding the causes, frequency, and severity of motorcoach fires. The final report of the Volpe study was expected by the end of 2007; the Board would appreciate receiving a copy of the report when it becomes available. The FMCSA also published a notice in the July 24, 2007, Federal Register, titled Regulatory Guidance for Recording of Commercial Motor Vehicle Accidents Involving Fires, reminding the truck and bus industries and Federal, State, and local motor carrier safety officials about the conditions, reasons, and standards under which certain CMV fires must be (1) recorded on a motor carrier’s accident register and (2) considered under the Accident Factor in applying the agency’s safety fitness procedures. This guidance emphasizes the importance of recording CMV accidents, as defined under Title 49 Code of Federal Regulations 390.5, that do not necessarily involve collisions and ensures that reports about CMV fires will be uploaded into the FMCSA’s Motor Carrier Management Information System. The FMCSA plans to conduct another study, in 2008, that will (1) extend the efforts initiated under the Volpe study and (2) ensure that information on the causes, frequency, and severity of bus and motorcoach fires continues to be gathered and evaluated. This effort will include an evaluation of the 2005 National Fire Incident Reporting System (NFIRS) data and State crash reporting. The Safety Board notes that the FMCSA will also consider working with the U.S. Fire Administration to explore the feasibility of modifying the NFIRS data set. The FMCSA initiated a root cause analysis for a limited number of bus and motorcoach fires, the results of which will be used, after completion of the study in mid-2009, in cooperation with the National Highway Traffic Safety Administration (NHTSA) to identify potential approaches for improving motorcoach occupant protection through enhanced fire prevention and mitigation; improved occupant evacuation; improved inspection, repair, and maintenance practices; or other measures. The FMCSA also established a quarterly meeting schedule with NHTSA’s Office of Defects Investigation to review all defect investigations specifically relating to CMVs. Although the Safety Board supports these initiatives and looks forward to receiving and reviewing the Volpe study when it is available, the Board is concerned that the gathering and analysis of bus and motorcoach fire data by the FMCSA Volpe contract and the other studies initiated by the FMCSA will not provide for ongoing statistical compilation and study. The Board remains firm in the belief that continuing analysis of motorcoach and bus fire data is vital in understanding not only the trends in these vehicle fires, but also the success or shortcomings of measures taken by the government and private industry to address this problem. Accordingly, pending completion of actions to satisfy the intent of this recommendation, Safety Recommendation H-07-1 is classified OPEN -- ACCEPTABLE RESPONSE.

From: FMCSA
To: NTSB
Date: 12/3/2007
Response: Letter Mail Controlled 12/3/2007 3:13:06 PM MC# 2070701: - From John H. Hill, Administrator: The FMCSA agrees with safety recommendation H-07-01 and is committed to continuing our current efforts to gather and evaluate information on the causes, frequency, and severity of bus and motorcoach fires. The Agency is engaged in several activities concerning the collection and analysis of fire data in an effort to enhance the safety of commercial motor vehicles (CMV). On July 24, 2007, FMCSA published a notice in the Federal Register titled Regulatory Guidance for Recording of Commercial Motor Vehicle Accidents Involving Fires. This regulatory guidance reminded the truck and bus industries and Federal, State, and local motor carrier safety officials about the conditions, reasons, and standards under which certain CMV fires must be (1) recorded on a motor carrier’s accident register, and (2) considered under the Accident Factor in applying the Agency’s safety fitness procedures. It historically has been our position that the definition of accident under 49 CFR 390.5 applies to both collision and non-collision incidents involving CMVs. If a fire results in a fatality, an injury, or disabling damage to a motor vehicle, it must be considered a recordable accident based on the current regulatory definition under 49 CFR 390.5. This guidance emphasizes the importance of recording CMV accidents (i.e., crashes), as defined under 49 CFR 390.5, that do not necessarily involve collisions and ensures that reports about CMV fires will be uploaded into the Agency’s Motor Carrier Management Information System. Prior to the Safety Board’s adoption of Highway Accident Report NTSB/HAR-07/01, Motorcoach Fire on Interstate 35 During Hurricane Rita Evacuation Near Wilmer, Texas, September 23, 2005, FMCSA entered into an agreement with the U.S. Department of Transportation’s Volpe National Transportation Systems Center (Volpe) to conduct a motorcoach fire safety analysis study. The primary objective of this study is to gather and analyze information regarding the causes, frequency, and severity of motorcoach fires. A secondary objective of this study is to identify potential ways to prevent, reduce, or mitigate the severity and frequency of motorcoach fires. To address the second objective, the study focused on (1) the effectiveness of motorcoach operational inspection practices, and (2) currently available fire detection and suppression systems. The final report is expected to be published later this year, and FMCSA will provide a copy to the NTSB. The FMCSA is planning to conduct a follow-on study in 2008 that will (1) extend the scope of the efforts initiated under the work described above, and (2) ensure that information on the causes, frequency, and severity of bus and motorcoach fires continues to be gathered and evaluated. This follow-on effort will include an evaluation of the 2005 National Fire Incident Reporting System (NFIRS) data, along with State crash reporting. The FMCSA will also consider working with the U.S. Fire Administration to explore the feasibility of modifying the NFIRS data set to collect additional motorcoach information that may be useful in determining the causes of motorcoach fires, and measuring the effectiveness of specific fire prevention and mitigation techniques. In addition, FMCSA has initiated a study to conduct a detailed engineering root cause analysis for a limited number of bus and motorcoach fires. A root cause analysis is a proven method for investigating the causes of incidents with safety, health, environmental, quality, reliability, and/or production-process impacts. Root cause analyses enable the generation of specific recommendations for preventing incident recurrences. The FMCSA and the National Highway Traffic Safety Administration (NHTSA) plan to use the results of this study to identify potential approaches for improving motorcoach occupant protection through enhanced fire prevention and mitigation; improved occupant evacuation; improved inspection, repair, and maintenance practices; or other measures. This study is scheduled to be completed in mid-2009. The FMCSA also established a quarterly meeting schedule with NHTSA’s Office of Defects Investigation to review all defect investigations specifically relating to CMVs. Using data and information gathered by Federal and State motor carrier safety enforcement personnel, FMCSA will assist NHTSA in gathering potential CMV defect information that could be used in identifying important trends, specifically with respect to bus and motorcoach fires. Based on the above, FMCSA requests that Safety Recommendation H-07-0 1 be classified as Closed Acceptable Response.