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Safety Recommendation Details

Safety Recommendation H-11-002
Synopsis: On October 22, 2009, about 10:38 a.m. eastern daylight time, a 2006 Navistar International truck-tractor in combination with a 1994 Mississippi Tank Company MC331 specification cargo tank semitrailer (the combination unit), operated by AmeriGas Propane, L.P., and laden with 9,001 gallons of liquefied petroleum gas, rolled over on a connection ramp after exiting Interstate 69 (I-69) southbound to proceed south on Interstate 465 (I-465), about 10 miles northeast of downtown Indianapolis, Indiana. The truck driver was negotiating a left curve in the right lane on the connection ramp, which consisted of two southbound lanes, when the combination unit began to encroach upon the left lane, occupied by a 2007 Volvo S40 passenger car. The truck driver responded to the Volvo’s presence in the left lane by oversteering clockwise, causing the combination unit to veer to the right and travel onto the paved right shoulder. Moments later, the truck driver steered counterclockwise to redirect and return the combination unit from the right shoulder to the right lane. The truck driver’s excessive, rapid, evasive steering maneuver triggered a sequence of events that caused the cargo tank semitrailer to roll over, decouple from the truck-tractor, penetrate a steel W-beam guardrail, and collide with a bridge footing and concrete pier column supporting the southbound I-465 overpass. The collision entirely displaced the outside bridge pier column from its footing and resulted in a breach at the front of the cargo tank that allowed the liquefied petroleum gas to escape, form a vapor cloud, and ignite. The truck-tractor came to rest on its right side south of the I-465 overpasses, and the decoupled cargo tank semitrailer came to rest on its left side, near the bridge footing supporting the southbound I-465 overpass. The truck driver and the Volvo driver sustained serious injuries in the accident and postaccident fire, and three occupants of passenger vehicles traveling on I-465 received minor injuries from the postaccident fire. The National Transportation Safety Board (NTSB) determined that the probable cause of this accident was the excessive, rapid, evasive steering maneuver that the truck driver executed after the combination unit began to encroach upon the occupied left lane. Contributing to the rollover was the driver’s quickly steering the combination unit from the right shoulder to the right lane, the reduced cross slope of the paved right shoulder, and the susceptibility of the combination unit to rollover because of its high center of gravity. Mitigating the severity of the accident was the bridge design, including the elements of continuity and redundancy, which prevented the structure from collapsing. A basic requirement for evaluating the accident performance of U.S. Department of Transportation (DOT) specification cargo tanks (such as the MC331 involved in this accident) is access to data that can be used to quantify both the involvement of those tanks in reportable incidents and the in-service population of those same tanks. While the approximate number of DOT specification cargo tanks involved in accidents may be obtained from the Hazardous Materials Information System or other databases, there is limited access to accurate information on the population of cargo tanks by DOT specification. For example, the most precise number of petroleum-hauling DOT 406 cargo tank semitrailers cited in the Cargo Tank Roll Stability Study2 appeared to be somewhere between 10,648–60,003 units. When asked at the August 2010 NTSB public hearing, a Pipeline and Hazardous Materials Safety Administration (PHMSA) official acknowledged that the agency did not know the total number of cargo tanks by DOT specification that were currently in service.3 Further, PHMSA indicated that data analyses for evaluating the performance of DOT specification cargo tanks could be enhanced if the population of cargo tanks by DOT specification were available. The NTSB concludes that the absence of a requirement for motor carriers to periodically provide the number of cargo tanks by DOT specification limits the ability to perform accurate trend analyses. The limited information currently available for PHMSA to quantify the distribution of cargo tanks by DOT specification differs considerably, for example, from information that can be accessed by the Association of American Railroads (AAR) about tank cars used for transporting bulk liquids by rail. The AAR has used the Universal Machine Language Equipment Register (UMLER) equipment management information system as the industry’s central repository for registered railroad and intermodal equipment since 1968. The UMLER system is updated in real time and capable of tracking equipment status, ownership, and inspection history and providing the particular fleet profile.
Recommendation: TO THE FEDERAL MOTOR CARRIER SAFETY ADMINISTRATION: Work with the Pipeline and Hazardous Materials Safety Administration, as appropriate, to develop and disseminate guidance that will assist hazardous materials carriers in implementing comprehensive cargo tank motor vehicle rollover prevention programs, including the active participation of drivers, dispatchers, and management through training, loading practices, delivery schedules, and acquisition of equipment.
Original recommendation transmittal letter: PDF
Overall Status: Closed - Acceptable Action
Mode: Highway
Location: Indianapolis, IN, United States
Is Reiterated: No
Is Hazmat: No
Accident #: HWY10MH001
Accident Reports:
Rollover of a Truck-Tractor and Cargo Tank Semitrailer Carrying Liquified Petroleum Gas and Subsequent Fire
Report #: HAR-11-01
Accident Date: 10/22/2009
Issue Date: 9/2/2011
Date Closed: 7/6/2016
Addressee(s) and Addressee Status: FMCSA (Closed - Acceptable Action)
Keyword(s): Hazmat

Safety Recommendation History
From: NTSB
Date: 7/6/2016
Response: We are pleased to learn of your collaborative efforts with PHMSA to develop and distribute the recommended information. We further commend you for your continued efforts to educate drivers about the prevention of cargo tank motor vehicle rollovers. These actions satisfy the intent of Safety Recommendation H-11-2, which is classified CLOSED—ACCEPTABLE ACTION.

Date: 12/23/2015
Response: -From Michael Jordan, Management and Program Analyst, Strategic Planning and Program Evaluation Division, Federal Motor Carrier Safety Administration: • The Pipeline and Hazardous Materials Safety Administration (PHMSA) sponsored a research project through the Transportation Research Board (TRB) entitled, “Role of Human Factors in Preventing Cargo tank Rollovers,” which included FMCSA participation on the project panel. The project analyzed the causes of the major driver factors contributing to cargo tank motor vehicle rollovers and proposed safety, management, and communication practices that could potentially decrease driver errors in cargo tank motor vehicle operations. A report was published in 2012 and is available via the TRB Web site at • FMCSA dedicated a section on its Web site at to the prevention of cargo tank rollovers. • In an attempt to measure the impact of the Cargo Tank Rollover Prevention video featured on FMCSA’s rollover prevention Web site, the National Tank Truck Carriers (NTTC) circulated surveys to its membership following the release of the video and again during June 2012. Over 33,000 employees from member companies had viewed the video, and there were indications that some companies had shared the video with persons outside of the safety department and their drivers, including insurance companies, shippers, dispatchers, and managers. • The Cargo Tank Rollover Prevention video remains the focal point of FMCSA’s rollover prevention program. Both FMCSA and PHMSA continue to promote and disseminate the video by various media, such as our respective Web sites, outreach resources at conferences, multi-modal training seminars and workshops, social media, and outreach and training materials. For example, FMCSA features the video at end of every fiscal year as a reminder to the cargo tank industry about the importance of rollover prevention training. The video was featured on FMCSA’s Web site during the last week of September 2015. FMCSA requests that NTSB close Safety Recommendation H-11-002.

From: NTSB
Date: 9/13/2012
Response: The NTSB notes that the FMCSA released a new cargo tank rollover prevention video in August 2010. In addition, the FMCSA is working with the Transportation Research Board to study human factors as they relate to cargo tank rollovers; the agency has also met with PHMSA to discuss the development and dissemination of rollover prevention guidance. Pending the release of the recommended guidance, the FMCSA and its partners—PHMSA and the National Tank Truck Carriers organization—continue to promote the use of the 2010 video as an interim training tool. Accordingly, Safety Recommendation H-11-2 is classified OPEN—ACCEPTABLE RESPONSE pending completion and dissemination of the recommended guidance.

Date: 1/3/2012
Response: -From Anne S. Ferro, Administrator: The FMCSA strives to improve the safety of cargo tank motor vehicles on the Nation's highways. The Agency enforces related rules and regulations, conducts inspections, issues permits to certain hazmat carriers, conducts studies, issues advisory notices, and provides educational resources to assist in the safe movement of cargo tanks. In August 2010, FMCSA released a new cargo tank rollover prevention video. The updated video provides cargo tank drivers with best practices and safety tips on how to avoid rollover crashes while transporting hazardous materials. Developed in partnership with the Department's Pipeline and Hazardous Materials Safety Administration (PHMSA) and the National Tank Truck Carriers (NTTC), the "Cargo Tank Driver Rollover Prevention Video" uses driver interviews and on-road scenarios to highlight the factors that contribute to rollovers. Since its release in 20 10, the Agency has mailed over 22,000 DVDs to motor carriers in North America. The FMCSA also re-released the video in August 2011, making it available in Spanish and downloadable from the FMCSA website in both English and Spanish. To date, the video has received approximately 65,000 hits on the web. Major companies, such as Exxon and Boeing have reached out to FMCSA to obtain copies of the video to incorporate into their own training programs. As a follow-up to the 2007 Cargo Tank Rollover Stability Study conducted by Battelle Memorial Institute in collaboration with Commercial Vehicle Safety Alliance (CVSA), on behalf of the FMCSA Hazardous Materials Division, the Agency is currently working with the Transportation Research Board (TRB) on a study that will focus on human factors as they relate to cargo tank rollovers. This follow-up study is estimated to be completed by spring 2012 and the results will be shared with the industry as additional guidance on preventing rollover incidents. The Agency has met with PHMSA to discuss strategies for development and dissemination of guidance relating to cargo tank rollovers. The FMCSA is currently reviewing the feasibility of expanding the scope of the video to make it a more comprehensive training tool and considering other training and outreach options to aid drivers and companies in avoiding rollover accidents. In the meantime, FMCSA and PHMSA, in partnership with NTTC, continue to promote use of the video as a training tool. Based on the reasons cited above in safety recommendation H-11-02, FMCSA respectfully requests that NTSB classify the safety recommendation "Open-Acceptable Action."