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Safety Recommendation Details

Safety Recommendation H-11-004
Details
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 PIPELINE AND HAZARDOUS MATERIALS SAFETY ADMINISTRATION: Work with the Federal Motor Carrier Safety Administration, as appropriate, to develop and disseminate guidance to 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
Is NPRM: 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: 1/6/2017
Addressee(s) and Addressee Status: PHMSA (Closed - Acceptable Action)
Keyword(s): Hazmat

Safety Recommendation History
From: NTSB
To: PHMSA
Date: 1/6/2017
Response: We are pleased by your efforts to address this recommendation, including (1) working with the FMCSA to develop and distribute a rollover prevention video for cargo tank drivers, (2) highlighting the FMCSA’s link to the American Transportation Research Institute interactive mapping system showing areas on US roadways with the highest frequency of large truck rollovers, (3) collaborating with the FMCSA in an ongoing investigation and root cause analysis of rollover incidents and the involved motor carriers, and (4) encouraging your Department of Transportation sister agencies to promulgate rulemaking, such as that seen in the areas of new driver training and vehicle technologies, that will improve cargo tank truck operational safety. These actions meet the intent of Safety Recommendation H 11-4, which is classified CLOSED—ACCEPTABLE ACTION.

From: PHMSA
To: NTSB
Date: 8/30/2016
Response: -From Marie Therese Dominguez, Administrator: Cargo Tank Driver Rollover Prevention Video PHMSA previously informed the NTSB of feedback received from the public regarding the release of the FMC SA Cargo Tank Driver Rollover Prevention video, as well as efforts to promote the video as an integral part of a hazardous material (hazmat) employer's training. To date, over 22,000 videos have been distributed to cargo tank motor carriers, industry associations, and truck driver training schools; and FMCSA has received nearly 50,000 combined hits on the internet versions. The video is available on YouTube, Twitter, and other social media outlets, all accessible through the FMCSA website. Moreover, FMCSA is aware of private companies that are currently using the rollover prevention video as a part of their training. Scottsdale Insurance of Minneapolis, Minnesota, for example, uses the video in its driver training for motor carrier clients. Exxon Worldwide also uses the video in its company training and further translated it into the many languages currently used by its varied employees. Likewise, Methanex Asia-Pacific, which is a partner in the American Chemistry Council's Responsible Care Program, has translated the video into Japanese for use in its operation in Japan. The video has even found utility for non-hazmat transport as the National Tank Truck Carriers (NTTC) has developed and distributed a version specific to the operation of water trucks used by fire fighters. The rollover prevention video remains the hallmark ofFMCSA's outreach tools in the effort to develop and disseminate guidance to assist entities in implementing a comprehensive rollover prevention program. Additionally, we remind the NTSB that FMCSA's "Cargo Tank Rollover Toolbox," which includes guidance information on rollover prevention in downloadable formats for drivers and companies, went live back in late 2013. Cargo Tank Truck Rollover Prevention Webpage I Interactive Mapping System PHMSA previously highlighted FMCSA's partnership with the American Transportation Research Institute (ATRI) to create an interactive mapping system of the United States roadways showing the places with the highest frequency of large truck rollovers. The ATRI Interactive Rollover Hotspot Map2 is now live and has been linked to the FMCSA Cargo Tank Truck Rollover Prevention webpage.3 Companies can utilize this information as part of training or as a preparatory tool in route planning. Further outreach efforts include cargo tank rollover prevention training for industry. FMCSA is specifically exploring the concept of a training program similar to the Cargo Tank Inspection Seminars conducted jointly by FMCSA and NTTC. FMCSA is also considering making training available online to companies, associations, etc. Investigation I Root Cause Analysis PHMSA and FMC SA continue to collaborate in the investigation of rollover incidents and the motor carriers involved. With these continued efforts, we seek to better understand the factors leading to these incidents and to continuously improve guidance or potential regulatory requirements. The motor carriers involved in such incidents are being identified through a number of resources, including hazmat request notices (FMC SA forms used by their Divisions to report serious hazmat incidents), the Safety Measurement System (SMS), Emergency Response Center notices (usually e-mail notifications regarding serious crashes and hazmat incidents), and PHMSA incident reports. National Training Standards With respect to the training aspect of the recommendation, FMCSA has proposed a set of comprehensive national prerequisite training standards for those seeking to obtain a commercial driver's license (CDL). The notice of proposed rulemaking (NPRM), published in the Federal Register on March 7, 2016 (81 FR 11944), reflects consensus recommendations on entry-level driver training standards by a negotiated rulemaking committee (i.e., the Entry Level Driver Training Advisory Committee (ELDTAC)) comprised of FMCSA representatives and 25 stakeholders and responds to a Congressional mandate under the Moving Ahead for Progress in the 21st Century Act. The NPRM proposes that applicants seeking a "Class A" COL-necessary for operating a combination tractor-trailer type vehicle weighing 26,001 lbs. or more-would be required to obtain a minimum of 30 hours of behind-the-wheel training from an instructional program that meets FMC SA standards, including a minimum of 10 hours of operating the vehicle on a practice driving range. Applicants seeking a "Class B" CDL necessary for operating a heavy straight truck (such as a dump truck or box truck)-would be required to obtain a minimum of 15 hours of behind-the-wheel training, including a minimum of seven hours of practice range training. Applicants seeking a hazmat endorsement on his or her COL would need to complete further "theory" training that covers a minimum set of topics in the curriculum (e.g., specialized requirements for transportation of bulk packages, route planning, etc.). Although there is no proposed minimum hours of this further training, FMCSA will be providing additional guidance on available resources to supplement a curriculum (e.g., the Cargo Tank Rollover Toolbox). Under this proposal, the following individuals in all 50 states, the District of Columbia, and all U.S. territories would be subject to mandatory, comprehensive training: • First-time CDL applicants; • Current COL holders seeking a license upgrade (e.g., a Class B CDL holder seeking a Class A COL) or an additional endorsement (e.g., to transport hazmat); and • A previously disqualified CDL holder seeking to reacquire a license. These individuals would be subject to the proposed entry-level driver training requirements and must complete a course of instruction provided by a registered entity that meets the minimum qualifications for training providers and covers the approved curriculum, after which a certificate of completion of training must be transmitted electronically to FMCSA. Rulemaking Efforts The National Highway Transportation Safety Administration (NHTSA) published a final rule4 that establishes a new Federal Motor Vehicle Safety Standard No. 136 to require electronic stability control (ESC) systems on truck tractors with a gross vehicle weight rating (GVWR) of greater than 26,000 pounds. ESC systems in truck tractors are designed to reduce untripped rollovers and mitigate severe understeer or oversteer conditions that lead to loss of control by using automatic computer controlled braking and reducing engine torque output. Although the final rule does not apply to vehicles with a GVWR greater than 10,000 pounds up to 26,000 pounds as recommended by the NTSB, we believe the rule will still have a meaningful impact on hazmat transportation safety for those tractor trailer combinations transporting bulk quantities of material that require a tractor with a GVWR greater than 26,000 pounds. From January 2006 through May 2016, there were approximately 1,800 rollover incidents involving cargo tank motor vehicles (or "tank trucks") contributing to approximately 50 fatalities, or an average of about 170 rollovers and five fatalities annually. Assuming a similar trend through 2018 when new heavy trucks will have to be installed with ESC systems and using the effectiveness rates developed by NHTSA, our best-case scenario estimate is that this rule would prevent 32--45 rollovers and one fatality annually. We acknowledge uncertainty in the data and effectiveness of ESC systems under certain accident scenarios (e.g., liquid sloshing), but the estimate is such that even ifthere is a departure from the best-case scenario, there is opportunity for further prevention of roll overs and associated fatalities, injuries, and harm to the public and the ,environment from installation of this equipment. In summary, we believe these Department-wide actions combine to address the intent of Safety Recommendation H-11-4. Specifically, the combination of guidance material, training requirements, and equipment installation act to fulfill the intent of a comprehensive rollover prevention program, and therefore I request that NTSB change the status of this recommendation to "Closed - Acceptable Alternate Action."

From: NTSB
To: PHMSA
Date: 7/8/2013
Response: We are encouraged by the efforts that PHMSA and the FMCSA have already completed to address this recommendation, including (1) development and distribution of a rollover prevention video for cargo tank drivers, (2) creation of an interactive mapping system showing areas on US roadways with the highest frequency of large truck rollovers, and (3) a research project analyzing driver-related factors and countermeasures relating to cargo tank motor vehicle rollovers. Pending completion of actions based on analysis of the human factors research project, Safety Recommendation H-11-4 is classified OPEN—ACCEPTABLE RESPONSE.

From: PHMSA
To: NTSB
Date: 4/24/2013
Response: -From Cynthia L. Quarterman, Administrator: In our November 22, 2011 letter, we highlighted a Cargo Tank Driver Rollover Prevention video produced by FMCSA and PHMSA. Following its release, the National Tank Truck Carriers circulated surveys to its members to measure the impact and effectiveness of this video. Members that provided feedback generally had a positive view of the video. This feedback also indicated that over 33,000 employees from member companies had viewed the video, and that companies had shared the video with their safety departments, drivers, insurance companies, shippers, dispatchers, and managers. This video will remain an important part of PHMSA's and FMCSA's rollover prevention program. We will promote it as essential to a hazmat employer's training and will emphasize that the video should be shared with a broader audience than hazmat employees, such as dispatchers and managers. We regularly consider options to enhance the video or to provide additional guidance to persons associated with drivers. We also continue to promote and disseminate the video via our respective websites and promote awareness of the video via conferences, multi-modal training seminars and workshops, social media, and training materials. PHMSA is augmenting its Hazardous Materials Transportation Training Module 5.1 by adding a section that will include information about the rollover video, and FMCSA will prominently feature the video on its website and highlight the video to remind the cargo tank industry about the importance of rollover prevention training. Additionally, FMCSA, in partnership with the American Transportation Research Institute, will create an interactive mapping system of the United States roadways showing the places with the highest frequency of large truck rollovers. The FMC SA website will maintain a link to this mapping system, and will provide the public with an electronic bulletin board to contribute information on rollover events such as rollover hotspots. Finally, PHMSA has sponsored a research project by the Transportation Research Board (TRB) entitled "Role of Human Factors in Preventing Cargo Tank Rollovers" with FMCSA participation. The project analyzed the major driver-related factors contributing to cargo tank motor vehicle rollovers and proposed safety, management, and communication practices that could potentially decrease driver errors. PHMSA and FMCSA are reviewing the report for possible further actions in augmenting our comprehensive rollover prevention program.

From: NTSB
To: PHMSA
Date: 1/10/2012
Response: The NTSB understands that PHMSA and the FMCSA have discussed strategies for developing and disseminating guidance as it relates to cargo tank rollovers and that they and the National Tank Truck Carriers (NTTC) developed the video Cargo Tank Driver Rollover Prevention as a training tool. This video, available since August 2010 and accessible (both through the FMCSA and PHMSA websites and as a DVD) to hazardous materials motor carriers, has been viewed approximately 60,000 times. Further, the NTTC recently updated the video to include Spanish subtitles, thus making it accessible to Spanish-speaking commercial motor vehicle drivers as well. The NTSB is encouraged that PHMSA and the FMCSA plan to expand the video’s scope to make it a more comprehensive training tool to aid drivers and companies in avoiding rollover accidents. We note that PHMSA and the FMCSA, in partnership with the NTTC, will continue to promote the video and that PHMSA is considering other strategies for the development and dissemination of further guidance, such as having its Hazardous Materials Safety Assistance Team (HMSAT) work with the Commercial Vehicle Safety Alliance’s Training and Hazmat Committee to explore other ways to address this issue. Accordingly, Safety Recommendation H-11-4 is classified OPEN—ACCEPTABLE RESPONSE, pending the completion of PHMSA’s and the FMCSA’s efforts to develop and implement the recommended prevention programs.

From: PHMSA
To: NTSB
Date: 11/22/2011
Response: -From Cynthia L. Quarterman, Administrator: Since receiving the NTSB letter, PHMSA has met with FMCSA to discuss strategies for developing and disseminating guidance as it relates to cargo tank rollovers. FMCSA, in partnership with PHMSA and the National Tank Truck Carriers (NTTC), developed the Cargo Tank Driver Rollover Prevention video as a training tool. This video was made available August 3, 2010 and has been accessible through FMCSA and PHMSA websites as well as through distribution of a DVD to motor carriers that were identified as transporting hazardous materials in cargo tank motor vehicles. Since going live, there have been approximately 60,000 viewings of the video from the Department websites. Additionally, NTTC recently provided an updated version of the video to including Spanish subtitles to accommodate the ever-growing population of Spanish-speaking commercial motor vehicle drivers. PHMSA and FMCSA discussed the possibility of expanding the scope of the video to make it a more comprehensive training tool. FMCSA is currently reviewing the feasibility of this and other training and outreach options to aid drivers and companies in avoiding rollover accidents. In the meantime, PHMSA and FMCSA, in partnership with NTTC continue to promote use of the video as a training tool, and FMCSA showcased the video on its website to celebrate the first anniversary of its release. Also, PHMSA will consider other strategies to aid development and dissemination of any further guidance such as having PHMSA’s Hazardous Materials Safety Assistance Team (HMSAT) work with the Commercial Vehicle Safety Alliance’s Training and Hazmat Committee to explore alternatives. PHMSA will continue to work with FMCSA throughout this process and will update NTSB accordingly.