Highway Accident Report - Motorcoach Fire on Interstate 45
During Hurricane Rita Evacuation

Near Wilmer, Texas
September 23, 2005

NTSB Number: HAR-07-01
NTIS Number: PB2007-916202
Adopted February 21, 2007
PDF

Executive Summary

On September 23, 2005, a 1998 Motor Coach Industries, Inc. (MCI), 54-passenger motorcoach, operated by Global Limo Inc., 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.

Probable Cause

The National Transportation Safety Board determines that the probable cause of the accident was insufficient lubrication in the right-side tag axle wheel bearing assembly of the motorcoach, resulting in increased temperatures and subsequent failed wheel bearings, which led to ignition of the tire and the catastrophic fire. Global Limo Inc. had failed to conduct proper vehicle maintenance, to do pretrip inspections, and to complete posttrip driver vehicle inspection reports, thereby allowing the insufficient wheel bearing lubrication to go undetected. Contributing to the accident was the Federal Motor Carrier Safety Administration's ineffective compliance review system, which resulted in inadequate safety oversight of passenger motor carriers. Contributing to the rapid propagation and severity of the fire and subsequent loss of life was the lack of motorcoach fire-retardant construction materials adjacent to the wheel well. Also contributing to the severity of the accident was the limited ability of passengers with special needs to evacuate the motorcoach.

The following safety issues were identified in this investigation:

  • Vehicle fire reporting and inconsistent data within Federal accident databases,
  • Federal Motor Carrier Safety Administration's ineffective compliance review program,
  • Emergency egress from motorcoaches,
  • Fire resistance of motorcoach materials and designs,
  • Manufacturer maintenance information on wheel bearing components,
  • Transportation of partially pressurized aluminum cylinders, and
  • Emergency transportation of persons with special needs.

As a result of this accident investigation, the Safety Board makes recommendations to the Federal Motor Carrier Safety Administration, the National Highway Traffic Safety Administration, the Pipeline and Hazardous Materials Safety Administration, the Fraternal Order of Police, the International Association of Chiefs of Police, the International Association of Fire Chiefs, the International Association of Fire Fighters, the National Association of State EMS Officials, the National Sheriffs' Association, the National Volunteer Fire Council, Motor Coach Industries, Inc., and other motorcoach manufacturers, the United Motorcoach Association, and the American Bus Association. The Safety Board reiterates two recommendations to the U.S. Department of Transportation.

Recommendations

New Recommendations

As a result of its investigation, the National Transportation Safety Board makes the following safety recommendations:

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. (H-07-1)

Revise the Federal Motor Carrier Safety Regulations at 49 CFR 393.205 to prohibit a commercial vehicle from operating with wheel seal or other hub lubrication leaks. (H-07-2)

To protect the traveling public until completion of the Comprehensive Safety Analysis 2010 Initiative, immediately issue an Interim Rule to include all Federal Motor Carrier Safety Regulations in the current compliance review process so that all violations of regulations are reflected in the calculation of a carrier's final rating. (H-07-3)

To the National Highway Traffic Safety Administration:

Develop a Federal Motor Vehicle Safety Standard to provide enhanced fire protection of the fuel system in areas of motorcoaches and buses where the system may be exposed to the effects of a fire. (H-07-4)

Develop a Federal Motor Vehicle Safety Standard to provide fire-hardening of exterior fire-prone materials, such as those in areas around wheel wells, to limit the potential for flame spread into a motorcoach or bus passenger compartment. (H-07-5)

Develop detection systems to monitor the temperature of wheel well compartments in motorcoaches and buses to provide early warning of malfunctions that could lead to fires. (H-07-6)

Evaluate the need for a Federal Motor Vehicle Safety Standard that would require installation of fire detection and suppression systems on motorcoaches. (H-07-7)

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. (H-07-8)

To the Pipeline and Hazardous Materials Safety Administration:

Develop standards for the safe transportation of partially pressurized aluminum cylinders by, for example, requiring the addition of temperature-actuated pressure relief devices or the reduction of residual pressure to safe limits, to ensure that such cylinders do not experience overpressure failure when exposed to a fire. (I-07-1)

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. (I-07-2)

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 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. (I-07-3)

To Motor Coach Industries, Inc.:

Revise your product maintenance manuals to emphasize the importance of wheel bearing lubrication, specifically warning that daily inspection of hub oil levels and wheel seals is vital to prevent wheel bearing failure and that bypassing this requirement is a dangerous practice that can lead to a wheel well fire or other serious consequences. (H-07-9)

For those vehicles already sold and in service, disseminate a customer advisory bulletin on the importance of proper wheel bearing maintenance, specifying the type of equipment or oil bath bearings that require an undercarriage inspection to detect wheel seal leaks and alerting customers to the serious consequences of lack of lubrication and subsequent wheel bearing failure. (H-07-10)

To Motor Coach Industries, Inc., Prevost Car Inc., Setra, Van Hool, Blue Bird Corporation, Trident Industries, Inc., and IC Corporation:

Until the National Highway Traffic Safety Administration has developed a performance standard for enhanced fire protection of fuel systems in newly manufactured motorcoaches and included it in the Federal Motor Vehicle Safety Standards, as requested in Safety Recommendation (H-07-4), use materials and designs for fuel system components that are known to provide fire protection for the system. (H-07-11)

To the United Motorcoach Association and the American Bus Association:

Disseminate to your motorcoach and bus operator members an advisory bulletin emphasizing the importance of proper wheel bearing maintenance, particularly the importance of checking the oil level in oil-lubricated bearings (also known as oil bath bearings) and inspecting the undercarriage of the tag axle wheels to detect wheel seal leaks, and the serious consequences of lack of lubrication and subsequent wheel bearing failure. (H-07-12)

Advise your motorcoach manufacturer members to review product maintenance manuals and, if the manuals do not emphasize the importance of wheel bearing lubrication, to revise them to specifically warn that daily inspection of hub oil levels and wheel seals is vital to prevent wheel bearing failure and that bypassing this requirement is a dangerous practice that can lead to a wheel fire or other serious consequences. (H-07-13)

Advise your motorcoach manufacturer members to disseminate, for those vehicles already sold and in service, a customer advisory bulletin on the importance of proper wheel bearing maintenance, specifying the type of equipment or oil bath bearings that require an undercarriage inspection to detect wheel seal leaks and alerting customers to the serious consequences of lack of lubrication and subsequent wheel bearing failure. (H-07-14)

Reiterated Recommendations

The National Transportation Safety Board also reiterates the following two safety recommendations:

To the U.S. Department of Transportation:

Change the safety fitness rating methodology so that adverse vehicle or driver performance-based data alone are sufficient to result in an overall unsatisfactory rating for a carrier. (H-99-6)

Require motorcoach operators to provide passengers with pretrip safety information. (H-99-8)