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Safety Recommendation Details

Safety Recommendation I-07-002
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.1 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 PIPELINE AND HAZARDOUS MATERIALS SAFETY ADMINISTRATION: Issue guidance to, at a minimum, the Fraternal Order of Police, International Association of Chiefs of Police, International Association of Fire Chiefs, International Association of Fire Fighters, National Association of State EMS Officials, National Sheriffs’ Association, and National Volunteer Fire Council, describing the risk of overpressure failure of partially pressurized aluminum cylinders and the steps that should be taken to protect responders and the general public from a vehicle fire when aluminum cylinders are present.
Original recommendation transmittal letter: PDF
Overall Status: Closed - Acceptable Action
Mode: Intermodal
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: 2/4/2013
Addressee(s) and Addressee Status: PHMSA (Closed - Acceptable Action)
Keyword(s): Hazmat

Safety Recommendation History
From: NTSB
To: PHMSA
Date: 2/4/2013
Response: The NTSB is pleased that PHMSA has developed and distributed several documents to make the first responder community and the public aware of the safety risks present when compressed gases are transported in cylinders. PHMSA listed the following actions it has taken or is taking in response to this recommendation: • developed and issued guidance to bus and train operators to ensure safe handling and transport of medical oxygen cylinders for a passenger’s personal use • developed, published, and distributed the Emergency Response Guidebook to aid first responders in the identification of hazardous materials involved in an incident to protect themselves and the public • continues to issue safety advisory notices and safety alerts regarding improper requalification and marking of cylinders. As these actions satisfy the intent of Safety Recommendation I-07-2, the recommendation is classified CLOSED—ACCEPTABLE ACTION. Thank you for your continued efforts to improve the safety of first responders and the public during incidents where compressed gases transported in cylinders are present.

From: PHMSA
To: NTSB
Date: 8/10/2012
Response: -From Cynthia L. Quarterman, Administrator: PHMSA shares your concern for the safety of emergency responders and the general public. After the Wilmer, Texas incident and in the interest of improving public safety, PHMSA developed and issued guidance to bus and train operators to help assure that a medical oxygen cylinder being transported for a passenger’s personal use is handled and transported safely. The guidance included instructions to protect the cylinder valve from damage and to limit the quantity of cylinders. Following this guidance reduces the risk of overpressure failure of an aluminum cylinder used for medical oxygen should it become involved in a vehicle fire. In addition, PHMSA continues to work diligently to ensure that emergency responders have immediate access to information about the risks associated with the overpressure failure of cylinders whether constructed of aluminum or other material, or, whether fully or partially pressurized. PHMSA develops, publishes and distributes the Emergency Response Guidebook (ERG), which is used by firefighters, police, and other emergency services personnel who are often the first to arrive at the scene of a transportation incident involving hazardous material. The ERG is primarily a guide to aid first responders in: 1) quickly identifying the specific or generic classification of the material(s) involved in an incident, and 2) protecting themselves and the general public during the initial response phase of the incident. The ERG warns of the hazards of compressed gas in receptacles, such as a ruptured cylinder rocketing, and specifically addresses response measures and protective action distances in the case of compressed gas involved in a fire, such as instruction to move a receptacle from the fire, if possible. Finally, PHMSA continually issues safety advisory notices and safety alerts regarding improper requalification and marking of cylinders, aluminum cylinders included. These notices and alerts, available at our website at http://phmsa.dot.gov/hazmat/regs, result from PHMSA investigations and assist the public in understanding and resolving significant safety risks. Publication of such notices promotes safety by decreasing the potential for emergency responders and the public to be exposed to a cylinder that may not possess structural integrity in the event of a vehicle accident and fire. Thus, based on PHMSA guidance issued to operators following the Wilmer, Texas incident, the emergency response guidance on incidents involving compressed gas offered in the ERG, and the cylinder safety notices and alerts issued by PHMSA, I consider PHMSA’s actions complete with regard to Safety Recommendation I-07-2.

From: NTSB
To: PHMSA
Date: 11/7/2008
Response: The Safety Board notes that soon after the Wilmer, Texas, accident, PHMSA developed and issued guidance to bus and train operators to ensure the safe transportation and handling of medical oxygen being transported for passengers’ personal use. The Board further notes that PHMSA is working with the emergency response community to develop and disseminate guidance and training material concerning the risks associated with fires involving aluminum cylinders and the steps that should be taken to protect both emergency responders and the general public when such cylinders are involved in a vehicle fire. To that end, PHMSA is partnering with the International Association of Fire Chiefs to develop a shared information network for first responders the Hazmat Fusion Center of which a key function will be information dissemination of updated guidance and training. PHMSA is also working with the National Fire Academy to review the compressed gas cylinder training that is part of the Hazardous Material Responder curriculum, as well as with other emergency response organizations, such as the National Association of State Fire Marshals, and industry groups, such as the Compressed Gas Association, to develop and disseminate guidance and training information. As these actions address the intent of this recommendation, Safety Recommendation I-07-2 is classified OPEN ACCEPTABLE RESPONSE pending the completion and dissemination of the emergency response guidance. The Board would appreciate receiving a projected completion date for these efforts, confirmation once the guidance has been distributed, and a copy of the guidance distributed, for our records.

From: PHMSA
To: NTSB
Date: 1/22/2008
Response: Letter Mail Controlled 1/29/2008 8:57:01 AM MC# 2080033: - From Stacey L. Gerard, Assistant Administrator and Chief Safety Officer: In response to I-07-02, we will work with the emergency response community to develop and disseminate guidance and training material. Soon after the Wilmer, Texas accident, we developed and issued guidance to bus and train operators to assure that medical oxygen being transported for passengers’ personal use is handled and transported safely. We agree that emergency responders should receive guidance and training concerning the risks associated with fires involving aluminum cylinders and the steps that should be taken to protect both emergency responders and the general public when such cylinders are involved in a vehicle fire. We are partnering with the International Association of Fire Chiefs (IAFC) to develop a Hazmat Fusion Center, a shared information network for first responders. A key function of the Hazmat Fusion Center will be information dissemination, including updated hazardous materials training and guidance material for first responders. We are also working with the National Fire Academy to review the compressed gas cylinder training that is part of the Hazardous Material Responder curriculum. We will also work with other emergency response organizations, such as the National Association of State Fire Marshals, and industry groups, such as the Compressed Gas Association, to develop and disseminate guidance and training information.