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Safety Recommendation Details

Safety Recommendation H-07-008
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 current emergency evacuation designs of motorcoaches and buses by conducting simulation studies and evacuation drills that take into account, at a minimum, acceptable egress times for various 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.
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: We are pleased that you completed the recommended evaluation and published the final reports in your docket. These actions satisfy the intent of Safety Recommendation H-07-8, which is classified CLOSED--ACCEPTABLE ACTION.

From: NTSB
To: NHTSA
Date: 12/30/2015
Response:

From: NHTSA
To: NTSB
Date: 7/13/2015
Response: -From Mark R. Rosekind, Administrator: In 2010, NHTSA completed human factor research studies with the Volpe National Transportation System Center to evaluate emergency evacuation designs in current motorcoaches and buses. This work simulated motorcoach and bus emergency evacuation drills that addressed the issues raised by the NTSB in this recommendation. The final reports for this work were completed in 2010 and are published in Docket No. NHTSA-2007-28793-22 and -24. We request that this recommendation be classified as "Closed-Acceptable Action."

From: NTSB
To: NHTSA
Date: 2/10/2014
Response: We are encouraged by your progress in evaluating effective motorcoach passenger egress measures and urge you to act promptly to improve the current egress standards. Pending such action, Safety Recommendation H-07-8 remains classified OPEN—ACCEPTABLE RESPONSE.

From: NTSB
To: NHTSA
Date: 12/19/2008
Response: FMVSS No. 217 establishes current emergency egress requirements and also specifies the force with which emergency release mechanisms and emergency exits must operate for motorcoaches. Another Safety Board recommendation, H-99-9, also indicates our concerns with keeping the emergency exit open if the window is easily opened, particularly when the motorcoach is in a position that is not fully upright. NHTSA’s motorcoach plan will assess the most effective type, number, and required force to open emergency exits, as follows: 1.Identify studies from other modes (e.g., Federal Rail and Federal Aviation Administrations) and other regions (i.e., Europe) that may be applicable to bus emergency egress requirements, e.g., egress times, interior design (door, latch, hinges, signage), force levels for opening emergency exits, passenger response to egress designs, and any experimental and modeling efforts to study passenger responses during emergency egress. 2.Determine if any of the above could be directly applicable to motorcoaches. 3.If necessary, conduct human evacuation simulations of different emergency exit scenarios (including motorcoach, secondary exit door as in Europe, aircraft exits, etc.) and determine their effectiveness in reducing evacuation times. 4.If necessary, conduct human factor testing and analysis to develop an improved minimum strength requirement to open emergency exits. The analysis would include consideration for elderly occupants, while balancing the need for maintaining containment requirements. Determine the effectiveness of the procedure on improving evacuation. 5.Compile results of Tasks 3 and 4 to determine the feasibility and effectiveness of these approaches. NHTSA expects to complete this analysis in 2010. Pending the completion of this research to address the issue of improving emergency egress on motorcoaches, Safety Recommendation H-07-8 is 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 resdted in rollover. Ejection of passengers from motorcoaches zzcounts for approximately 55 percent of passenger fatalities. Among all motorcoach crashes from 1996-2005, 55 percent were single vehicle events and iiivo!ved 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 buszs 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 andor 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 bum rates, but also the toxicity of current materials and flame retardants. The agency’s motorcoach plan also outlines specific steps in the area of emergency egress. Emergency egress requirements for motorcoaches are established in FMVSS No. 2 17, which were adopted from what was the Interstate Commerce Commission’s Motor Carrier Safety Regulations. The number and type of emergency exits on buses and motorcoaches is based on seating capacity. Motorcoaches typically have 3-4 large emergency exit windows on each side, as well as a roof exit. FMVSS No. 21 7 also specifies the force with which emergency release mechanisms and emergency exits must operate. While the ease of opening the window in an emergency must be balanced against the need to keep it closed to prevent ejection, NTSB Safety Recommendation H-99-9 also noted concerns with keeping the emergency exit open if the window is easily opened, particularly when the motorcoach is in a position that is not fully upright. By 2010, the agency will assess the most effective type, number and required force to open emergency exits using the following approach. 1. Identify studies from other modes (e.g., Federal Rail & Federal Aviation Administrations) and other regions (ie., Europe) that may be applicable to bus emergency egress requirements, e.g., egress times, interior design (door, latch, hinges, signage), force levels for opening emergency exits, passenger response to egress designs, and any experimental and modeling efforts to study passenger responses during emergency egress. 2. Determine if any of the above could be directly applicable to motorcoaches. 3. If necessary, conduct human evacuation simulations of different emergency exit scenarios (including motorcoach, secondary exit door as in Europe, aircraft exits, etc.) and determine their effectiveness in reducing evacuation times. 4. If necessary, conduct human factor testing and analysis to develop an improved minimum strength requirement to open emergency exits. The analysis would include consideration for elderly occupants, while balancing the need for maintaining containment requirements. Determine the effectiveness of the procedure on improving evacuation. 5. Compile results of Tasks 3 and 4 to determine the feasibility and effectiveness of these approaches. 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."