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Safety Recommendation Details

Safety Recommendation I-07-003
Details
Synopsis: On September 23, 2005, a 1998 Motor Coach Industries, Inc., 54-passenger motorcoach, operated by Global Limo Inc., of Pharr, Texas, was traveling northbound on 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 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 THE NATIONAL VOLUNTEER FIRE COUNCIL: Disseminate to your members the guidance developed by the Pipeline and Hazardous Materials Safety Administration 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Overall Status: Closed--No Longer Applicable
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: 7/20/2015
Addressee(s) and Addressee Status: Fraternal Order of Police (Closed - Acceptable Action)
International Association of Chiefs of Police (Closed--No Longer Applicable)
International Association of Fire Chiefs (Closed--No Longer Applicable)
International Association of Fire Fighters (Closed--No Longer Applicable)
National Association of State EMS Officials (Closed--No Longer Applicable)
National Sheriffs' Association (Closed--No Longer Applicable)
National Volunteer Fire Council (Closed--No Longer Applicable)
Keyword(s): Hazmat

Safety Recommendation History
From: NTSB
To: International Association of Fire Fighters
Date: 7/20/2015
Response: Notation 8715: On June 30, 2006, PHMSA developed and issued “DOT Guidance for the Safe Transport of Medical Oxygen.” The guidance, which is addressed to truck and bus operators, explains PHMSA’s regulations regarding the transportation of medical oxygen on buses and trains and includes recommendations for handling oxygen cylinders. On February 4, 2013, Safety Recommendation I-07-2 was classified “Closed—Acceptable Action” because PHMSA had developed and issued the guidance to bus and train operators; had developed and distributed the Emergency Response Guidebook (ERG) to aid first responders in the identification of hazardous materials involved in an incident; and was continuing such actions as issuing safety advisory notices and safety alerts regarding improper requalification and marking of cylinders. However, PHMSA’s June 30, 2006, guidance is not addressed to the organizations to whom we issued Safety Recommendation I-07-3 (first responders) but rather to truck and bus operators, and the guidance in the ERG mainly describes how to identify medical oxygen tanks and the danger of their exploding and accelerating a fire, not the detailed information we asked PHMSA to provide. Staff concludes that, although the guidance developed and distributed by PHMSA to address Safety Recommendation I-07-2 is valuable and useful, it is not appropriate for use by the organizations to whom we issued Safety Recommendation I-07-3. Therefore, staff proposes that Safety Recommendation I-07-3 to the International Association of Fire Chiefs, the National Association of State EMS Officials, the National Sheriffs’ Association, and the National Volunteer Fire Council be classified “Closed—No Longer Applicable” and that it be re-classified CLOSED--NO LONGER APPLICABLE with regard to the International Association of Chiefs of Police and International Association of Firefighters.

From: NTSB
To: International Association of Fire Fighters
Date: 6/23/2014
Response: We have received no information from you about any actions that have been taken or planned in response to these recommendations. Accordingly, on June 16, 2011, we sent you a letter requesting an update on such actions, and on April 7, 2014, we sent an e mail to Mr. Barry Kasinitz, Director of Government Affairs, requesting similar information. Because we have been unable to learn, despite our repeated inquiries, whether you have taken or planned any action in response to these recommendations, Safety Recommendations R 02-4 and I-07-3 are classified CLOSED—UNACCEPTABLE ACTION/ NO RESPONSE RECEIVED.

From: NTSB
To: International Association of Fire Fighters
Date: 6/16/2011
Response: To date, the NTSB has received no information regarding the IAFF’s efforts to address Safety Recommendation R-02-4 or I-07-3. We would appreciate receiving an update regarding what, if anything, has been done to address these important safety issues. We are interested in knowing whether and how our recommendations are implemented, both to ensure the public the highest level of safety and to identify creative solutions that could be shared with others. Copies of the NTSB’s February 15, 2002, and June 27, 2007, letters are enclosed for your review. The full report of the Bourbonnais, Illinois, accident investigation (Report Number RAR-02-01) and the Wilmer, Texas, accident investigation (Report Number HAR07/01) are available on our website at www.ntsb.gov. If you have any questions, please contact Mr. Mike Brown at 202-314-6174 or at brownm@ntsb.gov.

From: NTSB
To: National Association of State EMS Officials
Date: 7/20/2015
Response: Notation 8715: On June 30, 2006, PHMSA developed and issued “DOT Guidance for the Safe Transport of Medical Oxygen.” The guidance, which is addressed to truck and bus operators, explains PHMSA’s regulations regarding the transportation of medical oxygen on buses and trains and includes recommendations for handling oxygen cylinders. On February 4, 2013, Safety Recommendation I-07-2 was classified “Closed—Acceptable Action” because PHMSA had developed and issued the guidance to bus and train operators; had developed and distributed the Emergency Response Guidebook (ERG) to aid first responders in the identification of hazardous materials involved in an incident; and was continuing such actions as issuing safety advisory notices and safety alerts regarding improper requalification and marking of cylinders. However, PHMSA’s June 30, 2006, guidance is not addressed to the organizations to whom we issued Safety Recommendation I-07-3 (first responders) but rather to truck and bus operators, and the guidance in the ERG mainly describes how to identify medical oxygen tanks and the danger of their exploding and accelerating a fire, not the detailed information we asked PHMSA to provide. Staff concludes that, although the guidance developed and distributed by PHMSA to address Safety Recommendation I-07-2 is valuable and useful, it is not appropriate for use by the organizations to whom we issued Safety Recommendation I-07-3. Therefore, staff proposes that Safety Recommendation I-07-3 to the International Association of Fire Chiefs, the National Association of State EMS Officials, the National Sheriffs’ Association, and the National Volunteer Fire Council be classified CLOSED--NO LONGER APPLICABLE and that it be re-classified “Closed—No Longer Applicable” with regard to the International Association of Chiefs of Police and International Association of Firefighters.

From: NTSB
To: National Association of State EMS Officials
Date: 6/14/2011
Response: To date, the NTSB has received no information regarding NASEMSO’s efforts to address Safety Recommendation I-07-3. We would appreciate receiving an update regarding what, if anything, has been done to address this important safety issue. We are interested in knowing whether and how our recommendations are implemented, both to ensure the public the highest level of safety and to identify creative solutions that could be shared with others. A copy of the NTSB’s June 27, 2007, letter is enclosed for your review, and the full report of the Wilmer, Texas, accident investigation (Report Number: HAR07/01) is available on our website at www.ntsb.gov. If you have any questions, please contact Mr. Mike Brown at 202-314-6174 or by e-mail at brownm@ntsb.gov.

From: NTSB
To: National Volunteer Fire Council
Date: 7/20/2015
Response: Notation 8715: On June 30, 2006, PHMSA developed and issued “DOT Guidance for the Safe Transport of Medical Oxygen.” The guidance, which is addressed to truck and bus operators, explains PHMSA’s regulations regarding the transportation of medical oxygen on buses and trains and includes recommendations for handling oxygen cylinders. On February 4, 2013, Safety Recommendation I-07-2 was classified “Closed—Acceptable Action” because PHMSA had developed and issued the guidance to bus and train operators; had developed and distributed the Emergency Response Guidebook (ERG) to aid first responders in the identification of hazardous materials involved in an incident; and was continuing such actions as issuing safety advisory notices and safety alerts regarding improper requalification and marking of cylinders. However, PHMSA’s June 30, 2006, guidance is not addressed to the organizations to whom we issued Safety Recommendation I-07-3 (first responders) but rather to truck and bus operators, and the guidance in the ERG mainly describes how to identify medical oxygen tanks and the danger of their exploding and accelerating a fire, not the detailed information we asked PHMSA to provide. Staff concludes that, although the guidance developed and distributed by PHMSA to address Safety Recommendation I-07-2 is valuable and useful, it is not appropriate for use by the organizations to whom we issued Safety Recommendation I-07-3. Therefore, staff proposes that Safety Recommendation I-07-3 to the International Association of Fire Chiefs, the National Association of State EMS Officials, the National Sheriffs’ Association, and the National Volunteer Fire Council be classified CLOSED--NO LONGER APPLICABLE and that it be re-classified “Closed—No Longer Applicable” with regard to the International Association of Chiefs of Police and International Association of Firefighters.

From: NTSB
To: National Volunteer Fire Council
Date: 6/14/2011
Response: To date, the NTSB has received no information regarding the NVC’s efforts to address Safety Recommendation I-07-3. We would appreciate receiving an update regarding what, if anything, has been done to address this important safety issue. The NTSB is interested in knowing whether and how its recommendations are implemented, both to ensure the public the highest level of safety and to identify creative solutions that could be shared with others. A copy of the NTSB’s June 27, 2007, letter is enclosed for your review; the full report of the Wilmer, Texas, accident investigation (Report Number HAR07/01) is available on our website at www.ntsb.gov. If you have any questions, please contact Mr. Mike Brown at 202-314-6174 or at brownm@ntsb.gov.

From: NTSB
To: National Sheriffs' Association
Date: 7/20/2015
Response: Notation 8715: On June 30, 2006, PHMSA developed and issued “DOT Guidance for the Safe Transport of Medical Oxygen.” The guidance, which is addressed to truck and bus operators, explains PHMSA’s regulations regarding the transportation of medical oxygen on buses and trains and includes recommendations for handling oxygen cylinders. On February 4, 2013, Safety Recommendation I-07-2 was classified “Closed—Acceptable Action” because PHMSA had developed and issued the guidance to bus and train operators; had developed and distributed the Emergency Response Guidebook (ERG) to aid first responders in the identification of hazardous materials involved in an incident; and was continuing such actions as issuing safety advisory notices and safety alerts regarding improper requalification and marking of cylinders. However, PHMSA’s June 30, 2006, guidance is not addressed to the organizations to whom we issued Safety Recommendation I-07-3 (first responders) but rather to truck and bus operators, and the guidance in the ERG mainly describes how to identify medical oxygen tanks and the danger of their exploding and accelerating a fire, not the detailed information we asked PHMSA to provide. Staff concludes that, although the guidance developed and distributed by PHMSA to address Safety Recommendation I-07-2 is valuable and useful, it is not appropriate for use by the organizations to whom we issued Safety Recommendation I-07-3. Therefore, staff proposes that Safety Recommendation I-07-3 to the International Association of Fire Chiefs, the National Association of State EMS Officials, the National Sheriffs’ Association, and the National Volunteer Fire Council be classified CLOSED--NO LONGER APPLICABLE and that it be re-classified “Closed—No Longer Applicable” with regard to the International Association of Chiefs of Police and International Association of Firefighters.

From: NTSB
To: National Sheriffs' Association
Date: 6/14/2011
Response: To date, the NTSB has received no information regarding the NSA’s efforts to address Safety Recommendation I-07-3. We would appreciate receiving a reply regarding what, if anything, has been done to address these important safety issues. The NTSB is interested in knowing whether and how its recommendations are implemented, both to ensure the public the highest level of safety and to identify creative solutions that could be shared with others. A copy of the NTSB’s June 27, 2007, letter is enclosed for your review, and the full report of the Wilmer, Texas, accident investigation (Report Number HAR07/01) is available on our website at www.ntsb.gov. If you have any questions, please contact Mr. Mike Brown at 202-314-6174 or at brownm@ntsb.gov.

From: NTSB
To: International Association of Chiefs of Police
Date: 7/20/2015
Response: Notation 8715: On June 30, 2006, PHMSA developed and issued “DOT Guidance for the Safe Transport of Medical Oxygen.” The guidance, which is addressed to truck and bus operators, explains PHMSA’s regulations regarding the transportation of medical oxygen on buses and trains and includes recommendations for handling oxygen cylinders. On February 4, 2013, Safety Recommendation I-07-2 was classified “Closed—Acceptable Action” because PHMSA had developed and issued the guidance to bus and train operators; had developed and distributed the Emergency Response Guidebook (ERG) to aid first responders in the identification of hazardous materials involved in an incident; and was continuing such actions as issuing safety advisory notices and safety alerts regarding improper requalification and marking of cylinders. However, PHMSA’s June 30, 2006, guidance is not addressed to the organizations to whom we issued Safety Recommendation I-07-3 (first responders) but rather to truck and bus operators, and the guidance in the ERG mainly describes how to identify medical oxygen tanks and the danger of their exploding and accelerating a fire, not the detailed information we asked PHMSA to provide. Staff concludes that, although the guidance developed and distributed by PHMSA to address Safety Recommendation I-07-2 is valuable and useful, it is not appropriate for use by the organizations to whom we issued Safety Recommendation I-07-3. Therefore, staff proposes that Safety Recommendation I-07-3 to the International Association of Fire Chiefs, the National Association of State EMS Officials, the National Sheriffs’ Association, and the National Volunteer Fire Council be classified “Closed—No Longer Applicable” and that it be re-classified CLOSED--NO LONGER APPLICABLE with regard to the International Association of Chiefs of Police and International Association of Firefighters.

From: NTSB
To: International Association of Chiefs of Police
Date: 5/5/2011
Response: On December 4, 2002, the NTSB sent a letter to the IACP requesting information on what action, if any, your organization had taken or had planned to take to implement Safety Recommendations H-01-36 and H-02-6. On April 22, 2010, the NTSB sent a letter requesting information on what action, if any, the IACP had taken or had planned to take to implement Safety Recommendations H-01-36, H-02-6 and A-09-138. On November 23, 2010, the NTSB sent a letter requesting information on what action, if any, IACP had taken or had planned to take to implement Safety Recommendations H-01-36, H-02-6, I-07-3 and A-09-138. With the exception of the IACP’s May 2, 2008, reply to the NTSB’s August 20, 2007, letter, which resulted in our classifying Safety Recommendation I-07-3 “Open—Acceptable Response,” we have received no information from the IACP regarding what, if anything, your organization has done to address these important safety issues. The NTSB is vitally interested in knowing whether and how its recommendations are implemented, both to ensure that the traveling public is provided the highest level of safety and to identify creative solutions that might be shared with others. That is why we monitor the implementation of all of our recommendations. Accordingly, because the NTSB has been unable to confirm that the IACP has completed action to address these issues, Safety Recommendations H-01-36, H-02-6, and A-09-138 are classified “Closed – Unacceptable Action/ No Response Received”, and Safety Recommendation I-07-3 is classified CLOSED – UNACCEPTABLE ACTION. Should the NTSB receive a timely response from you indicating that the IACP has acted to address these recommendations, with details of the actions taken, we may reevaluate their classifications.

From: NTSB
To: International Association of Chiefs of Police
Date: 5/2/2008
Response: Safety Board staff spoke with Mr. Daniel Cabrera and received a copy of the information that the IACP disseminated to its member law enforcement agencies, including (1) the lessons learned from this accident, (2) PHMSA guidance on risks associated with the overpressure failure of partially pressurized aluminum cylinders, and (3) the steps that should be taken to protect responders and the general public from a vehicle fire when aluminum cylinders are present. The Board commends the IACP for its prompt action; however, we would like to clarify that the PHMSA guidance you disseminated was preliminary information the agency made available following the Wilmer accident. The guidance indicated in Safety Recommendation I-07-3 refers to a project that PHMSA is currently working on in response to the Board’s Safety Recommendation I-07-2, also issued as a result of the Wilmer accident. When the new PHMSA guidance is completed, the Board encourages the IACP to distribute it to its members to complete action on this important safety issue regarding pressurized aluminum cylinders; we look forward to receiving a copy of the disseminated materials once they become available. Because these planned actions will satisfy this recommendation, Safety Recommendation I-07-3 is classified OPEN ACCEPTABLE RESPONSE pending dissemination of the final PHMSA guidelines.

From: International Association of Chiefs of Police
To: NTSB
Date: 8/20/2007
Response: Letter Mail Controlled 8/29/2007 10:05:12 AM MC# 2070444: - From James W. McMahon, Deputy Executive Director: The IACP fully supports your recommendation (1-07-3) Disseminating PHMSA guidelines for the safe transportation of medical oxygen for personal use on buses and trains. The IACP has today distributed to all of our member law enforcement agencies your investigative findings along with a copy of the PHMSA recommendations for their enlightenment and use should a similar evacuation be necessary in their jurisdictions at some future date. We appreciate you bringing this information to our attention, and if the IACP may be of further assistance in the future, please feel free to call on us. Very truly yours, James W. McMahon, Deputy Executive Director, International Association of Chiefs of Police, 5 15 N. Washington Street, Alexandria, VA 22314.

From: NTSB
To: International Association of Fire Chiefs
Date: 7/20/2015
Response: Notation 8715: On June 30, 2006, PHMSA developed and issued “DOT Guidance for the Safe Transport of Medical Oxygen.” The guidance, which is addressed to truck and bus operators, explains PHMSA’s regulations regarding the transportation of medical oxygen on buses and trains and includes recommendations for handling oxygen cylinders. On February 4, 2013, Safety Recommendation I-07-2 was classified “Closed—Acceptable Action” because PHMSA had developed and issued the guidance to bus and train operators; had developed and distributed the Emergency Response Guidebook (ERG) to aid first responders in the identification of hazardous materials involved in an incident; and was continuing such actions as issuing safety advisory notices and safety alerts regarding improper requalification and marking of cylinders. However, PHMSA’s June 30, 2006, guidance is not addressed to the organizations to whom we issued Safety Recommendation I-07-3 (first responders) but rather to truck and bus operators, and the guidance in the ERG mainly describes how to identify medical oxygen tanks and the danger of their exploding and accelerating a fire, not the detailed information we asked PHMSA to provide. Staff concludes that, although the guidance developed and distributed by PHMSA to address Safety Recommendation I-07-2 is valuable and useful, it is not appropriate for use by the organizations to whom we issued Safety Recommendation I-07-3. Therefore, staff proposes that Safety Recommendation I-07-3 to the International Association of Fire Chiefs, the National Association of State EMS Officials, the National Sheriffs’ Association, and the National Volunteer Fire Council be classified CLOSED--NO LONGER APPLICABLE and that it be re-classified “Closed—No Longer Applicable” with regard to the International Association of Chiefs of Police and International Association of Firefighters.

From: NTSB
To: International Association of Fire Chiefs
Date: 6/7/2011
Response: CC# 201100190: To date, the NTSB has received no information regarding the IAFC’s efforts to address Safety Recommendations I-07-3 and A-09-138; we would appreciate receiving an update regarding what, if anything, has been done to address these important safety issues. The NTSB is interested in knowing whether and how its recommendations are implemented, both to ensure the public the highest level of safety and to identify creative solutions that could be shared with others. Copies of the NTSB’s June 27, 2007, and November 13, 2009, letters are enclosed for your review. The full reports of the Wilmer, Texas, accident investigation (Report Number: HAR07/01) and the District Heights, Maryland, accident investigation (Report Number AAR-09-07) are available on our website at www.ntsb.gov. If you have any questions, please contact Mr. Mike Brown at 202-314-6174 or brownm@ntsb.gov.

From: NTSB
To: International Association of Fire Chiefs
Date: 5/2/2008
Response: The Safety Board notes that once the PHMSA guidance is published, the IAFC plans to include a news item in its newsletter, On-Scene, to distribute the information to its approximately 13,000 members. We look forward to receiving a copy of the issue of the newsletter containing the information. Because these planned actions will satisfy the recommendation, Safety Recommendation I-07-3 is classified OPEN -- ACCEPTABLE RESPONSE pending our review of the information published

From: International Association of Fire Chiefs
To: NTSB
Date: 8/14/2007
Response: Letter Mail Controlled 8/20/2007 1:16:45 PM MC# 2070419: - From Mark W. Light, Executive Director: Thank you for your letter advising the International Association of Fire Chiefs (IAFC) about the safety recommendations made as a result of your investigation of the September 23, 2005, motorcoach fire on Interstate 45, near Wilmer, Texas. The IAFC is committed to working with federal, state and local agencies to promulgate critical safety information to the leaders of the emergency services so that they can operate as safely as possible. We have investigated the status of the guidance from the Pipeline and Hazardous Materials Safety Administration and have been informed that they are beginning the process of responding to the recommendation. Once guidance is developed and published we will include a news item in our newsletter On-Scene distributing the information to our almost 13,000 members. I have assigned Shawn Stokes (sstokes@iafc.org, 703-537-4857) to follow-up on obtaining the information and working with your staff to ensure the information is distributed as appropriate.

From: NTSB
To: Fraternal Order of Police
Date: 9/6/2011
Response: The NTSB is pleased to learn, from the telephone conversations and e-mails between Mr. Richardson and my staff, that the FOP disseminated the information regarding aluminum cylinders to its membership as requested. Accordingly, Safety Recommendation I-07-3 is classified CLOSED—ACCEPTABLE ACTION.

From: NTSB
To: Fraternal Order of Police
Date: 6/15/2011
Response: To date, the NTSB has received no information regarding the FOP’s efforts to address Safety Recommendation I-07-3. We would appreciate receiving a reply regarding what, if anything, has been done to address this important safety issue. The NTSB is interested in knowing whether and how its recommendations are implemented, both to ensure the public the highest level of safety and to identify creative solutions that might be shared with others. A copy of the NTSB’s June 27, 2007, letter is enclosed for your review; the full report of the Wilmer, Texas, accident investigation (Report Number HAR07/01) is available on our website at www.ntsb.gov. If you have any questions, please contact Mr. Mike Brown at 202-314-6174 or at brownm@ntsb.gov.