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Safety Recommendation Details

Safety Recommendation H-07-007
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 NATIONAL HIGHWAY TRAFFIC SAFETY ADMINISTRATION: Evaluate the need for a Federal Motor Vehicle Safety Standard that would require installation of fire detection and suppression systems on motorcoaches.
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: 11/13/2017
Addressee(s) and Addressee Status: NHTSA (Closed - Acceptable Action)
Keyword(s):

Safety Recommendation History
From: NTSB
To: NHTSA
Date: 11/13/2017
Response: Although we are disappointed that you intend to take no further action regarding the recommended systems, we recognize that you completed the recommended evaluation and that your research did not sufficiently support you developing and publishing a fire detection and suppression system standard. Accordingly, Safety Recommendation H-07-7 is classified CLOSED--ACCEPTABLE ACTION.

From: NHTSA
To: NTSB
Date: 7/1/2016
Response: -From Mark R. Rosekind, Administrator: Developing FMVSS to address H-07-04 and H-07-05 would require fire protection systems around the fuel lines and exterior materials, and/or better locating the fuel lines. The former requires additional cost, which alternatively could be avoided with appropriate placement of the fuel lines. Such placement is highly dependent on vehicle design and not conducive to a performance-based FMVSS. Furthermore, in the 2016 update of a 2009 Federal Motor Carrier Safety Administration (FMCSA) report "Motorcoach Fire Safety Analysis," FMCSA noted that there was an association between out-of-service violations and the risk of fire involvement. Since FMCSA has significantly increased its safety enforcement of motorcoaches and other commercial passenger carriers in recent years, we believe there will be significantly fewer bus fires initiating in the wheel-well area, in general. Furthermore, our data show that such bus fires rarely result in occupant fatalities or injuries. Therefore, NHTSA believes there is greater benefit in alternative strategies, such as improving motorcoach egress to ensure occupant safety in the event of a fire, rather than fire hardening exterior bus materials around the wheel-well area. For these reasons, NHTSA will not pursue enhanced fire protection of the fuel system and fire hardening of exterior materials, as recommended in H -07-04 and -05. We intend no further action on these two Safety Recommendations and request that they be closed. In addressing H-07-06 and -07, NHTSA completed research with Southwest Research Institute in the development of test procedures evaluating fire detection and fire suppression systems. Our evaluation found that these test procedures are specific to particular bus designs and consequently are not conducive to a FMVSS. Alternatives to regulatory action, including industry standards and insurance incentives based on the presence of fire detection and suppression systems, may be a more prudent course of action. Therefore, our development and evaluation is complete and we intend no further action on Safety Recommendations H-07-06 or H-07-07. In summary, we are requesting that Safety Recommendations H-07-04- 07 be closed, as alternate, non-regulatory solutions provide more realistic safety benefits.

From: NTSB
To: NHTSA
Date: 2/10/2014
Response: We support your efforts to conduct root cause analysis of fire incidents and to evaluate fire detection and suppression systems, and fire-hardening materials, for motorcoaches, and we encourage you to act promptly to implement the beneficial findings of your research. Pending completion of the recommended actions, Safety Recommendations H-07-4 through -7 remain classified OPEN—ACCEPTABLE RESPONSE.

From: NTSB
To: NHTSA
Date: 12/19/2008
Response: Current fire protection on motorcoaches is subject to the requirements of FMVSS No. 302, Flammability of Interior Materials, established in 1972, with minor changes in 1975, which establishes burn resistance requirements for materials used in the occupant compartment. The existing standard does not address fires that originate outside the passenger compartment, as occurred in the Wilmer, Texas, accident. The Safety Board notes that NHTSA’s motorcoach plan includes an evaluation of existing fire protection tests and standards to assess their relevance to motorcoaches, as follows: 1.Review relevant studies that examine the cause of fires in motorcoaches. Based on the results of the studies, determine best approaches to prevent or mitigate the fire to maximize evacuation time for the bus passengers. 2.Identify existing flammability standards and test procedures and select those which would be most appropriate and/or applicable to motorcoach interior and exterior components. 3.Select materials both from the exterior of the motorcoach and within the compartment to test for their flammability. Selection would include both those materials currently found on the interior and exterior of motorcoaches, as well as flame retardant materials. 4.Conduct comparative testing on the selected materials using test procedures identified in Step #1, including baseline testing with the FMVSS No. 302 procedures. 5.Determine the performance with the various materials relative to established requirements of the respective procedures, and assess the need to adopt more stringent flammability requirements for both interior and external motorcoach components. The assessment would need to consider not only the burn rates, but also the toxicity of current materials and flame retardants. The Board has learned that NHTSA recently concluded a contract to work with the National Institute of Standards and Technology (NIST) on this analysis, which NHTSA expects to be completed by the end of fiscal year 2009. NHTSA staff informed Safety Board staff that a statement of work (SOW) was signed on June 13, 2008, outlining research on motorcoach flammability testing that NIST will conduct in cooperation with NHTSA. The SOW, now posted in NHTSA’s motorcoach safety docket, indicates that NHTSA and NIST will focus their testing on rear wheel-well and fuel-line area flammability, with plans to gather information on engine compartment fire propagation from ongoing full-scale motorcoach fire testing by the SP Swedish National Testing and Research Institute to complete the fire study. The Board notes that NIST will conduct a literature review, consult Federal and industry authorities on wheel-well fire propagation, evaluate and compare material flammability test methods, conduct wheel-well mockup studies, and assess countermeasures. When the research is complete, NIST will prepare a final report of the study results that NHTSA will analyze before considering rulemaking action. Pending the completion of this research and subsequent rulemaking to enhance and/or develop FMVSS to address the issue of improving the fire protection systems on motorcoaches, Safety Recommendations H-07-4 through -7 are classified OPEN -- ACCEPTABLE RESPONSE.

From: NHTSA
To: NTSB
Date: 10/25/2007
Response: Letter Mail Controlled 10/30/2007 12:48:12 PM MC# 2070614: - From Nicole R. Nason, Administrator: Motorcoach transportation has been a safe form of transportation in the United States. Between 1996 and 2005, there have been 48 fatal motorcoach crashes. During this period, on average, 14 fatalities have occurred annually to occupants of motorcoaches in crash and rollover events, with about 2 of those fatalities being drivers. Approximately 29 percent of the fatal crashes resulted in rollover. Ejection of passengers from motorcoaches accounts for approximately 55 percent of passenger fatalities. Among all motorcoach crashes from 1996-2005, 65 percent were single vehicle events and involved running off the road, hitting roadside objects, or rolling over. The tragic Wilmer, TX motorcoach fire that occurred during the Hurricane Rita evacuation is the only fatal incident associated with a fire. NHTSA participated as a party to the Board’s August 8-9, 2006, public meeting surrounding the Wilmer motorcoach fire. As a result of the testimony provided at this hearing, the Board’s related safety recommendations, and other ongoing internal agency regulatory reviews, NHTSA developed a plan to address motorcoach safety. (A copy of the document, titled NHTSA ’s Approach to Motorcoach Safety, has been provided to NTSB staff. An electronic version of the document is available at http://dms.dot.gov/, Docket No. NHTSA-2007-28793). As an agency, we looked at all aspects of the motorcoach safety issue, focusing on how best to make necessary progress in motorcoach safety within the next 2 years. Various potential prevention, mitigation, and evacuation approaches were considered in developing the plan. A number of considerations were weighed in determining the priorities. These considerations included: · Size of the target injury population and potential safety benefits that might be realized. ·Likelihood that the effort would lead to the desired and successful conclusion. ·Resources and time needed to carryout the research. ·NTSB “Most Wanted” listing. ·Anticipated cost of implementing the ensuing requirements into the motorcoach fleet. This plan specifically addresses the Wilmer bus fire recommendations. Currently, fire protection on motorcoaches stems from the requirements and test procedures identified in Federal Motor Vehicle Safety Standard (FMVSS) No. 302, “Flammability of interior materials.” This standard was established in 1972, with minor changes in 1975. Passenger cars, multipurpose passenger vehicles, trucks, and buses are subject to these requirements, the purpose of which is to establish burn resistance requirements for materials used in the occupant compartments of the aforementioned vehicles. The scope of the standard is to reduce deaths and injuries to the occupants of these vehicles in the event of fires in the interior of the vehicle from such sources as matches and cigarettes. The existing standard does not address fires that originate outside the passenger compartment, as occurred in the Wilmer incident. While fire protection improvement for some exterior components, such as tires, may not currently be practicable, mitigation of fires that originate in other locations such as the engine compartment or other external locations may be feasible to ensure that they do not propagate too rapidly into the occupant compartment, thus allowing time for egress. To this end, the agency will evaluate existing fire protection tests and standards to assess their relevance to motorcoaches. To do this, we have adopted the following strategic approach that we expect to complete in 2009. 1.Review relevant studies that examine the cause of fires in motorcoaches. Based on the results of the studies, determine best approaches to prevent or mitigate the fire to maximize evacuation time for the bus passengers. 2.Identify existing flammability standards and test procedures and select those which would be most appropriate and/or applicable to motorcoach interior and exterior components. 3.Select materials both from the exterior of the motorcoach and within the compartment to test for their flammability. Selection would include both those materials currently found on the interior and exterior of motorcoaches, as well as flame retardant materials. 4.Conduct comparative testing on the selected materials using test procedures identified in Step #1, including baseline testing with the FMVSS No. 302 procedures. 5.Determine the performance with the various materials relative to established requirements of the respective procedures, and assess the need to adopt more stringent flammability requirements for both interior and external motorcoach components. The assessment would need to consider not only the burn rates, but also the toxicity of current materials and flame retardants. In conclusion, this course of action to improve motorcoach fire safety and emergency egress will help us make progress in strategic areas that will help reduce fatalities as effectively as possible. NHTSA believes that these activities will, in a timely fashion, address NTSB’s concerns in the area of motorcoach fire safety. We request that these safety recommendations be classified as “Open—Acceptable Response. I hope that this information is helpful. If I can be of further assistance, please contact me or Mr. Ronald L. Medford, Senior Associate Administrator for Vehicle Safety.