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Safety Recommendation Details

Safety Recommendation H-89-004
Details
Synopsis: About 10:55 p.m. eastern daylight time on May 14, 1988, a pickup truck traveling northbound in the southbound lanes of interstate 71 struck head-on a church activity bus traveling southbound in the left lane of the highway near Carrollton, Kentucky. As the pickup truck rotated during impact, it struck a passenger car traveling southbound in the right lane near the church bus. The church bus fuel tank was punctured during the collision sequence, and a fire ensued, engulfing the entire bus. The bus driver and 26 bus passengers were fatally injured. Thirty-four bus passengers sustained minor to critical injuries, and six bus passengers were not injured. The pickup truck driver sustained serious injuries, but neither occupant of the passenger car was injured.
Recommendation: TO THE NATIONAL HIGHWAY TRAFFIC SAFETY ADMINISTRATION: Incorporate in Federal Motor Vehicle Safety Standard 302 the recommendations of the National Institute of Standards and Technology concerning the new material acceptance criteria to reduce the rate of fire spread in all buses.
Original recommendation transmittal letter: PDF
Overall Status: Closed - Acceptable Alternate Action
Mode: Highway
Location: Carrollton, KY, United States
Is Reiterated: No
Is Hazmat: No
Is NPRM: No
Accident #: DCA88MH004
Accident Reports: Pickup Truck/Church Activity Bus Head-on Collision and Fire
Report #: HAR-89-01
Accident Date: 5/14/1988
Issue Date: 6/5/1989
Date Closed: 12/17/1998
Addressee(s) and Addressee Status: NHTSA (Closed - Acceptable Alternate Action)
Keyword(s):

Safety Recommendation History
From: NTSB
To: NHTSA
Date: 12/17/1998
Response: Safety Recommendation H-89-4 asked NHTSA to incorporate in FMVSS 302 the recommendations of the National institute of Standards and Technology concerning the new material acceptance criteria to reduce the rate of fire spread in all buses. The Safety Board commends NHTSA for changing the emergency exit requirements so that school buses are required to have emergency exits" Additionally, NHTSA has written to each director of pupil transportation and each school bus manufacturer informing them that flame resistant materials are available that are more flame resistant than required by NHTSA's standard. States can impose more stringent flammability standards than are currently required by FMVSS 302" As a result of NHTSA's efforts to upgrade the emergency exit requirements for school buses, thus reducing the need to upgrade the flammability requirements for school bus seats, Safety Recommendation H-89-4 has been classified CLOSED—ACCEPTABLE ALTERNATE ACTION.

From: NHTSA
To: NTSB
Date: 7/31/1998
Response: There is no assurance that upgrading the flammability of school bus seats would have any effect on the outcome of a fuel-fed fire such as in the aforementioned crash. Also, most commenters to the NHTSA rulemaking believed that upgrading the standard would result in a significant cost increase for school buses. The cost increase estimates ranged from $275 to upgrade only the seat foam to $1,500 for the seat foam and a flame retardant cover for a typical 66-passenger school bus. NHTSA has written to each state director of pupil transportation and each school bus manufacturer informing them that flame resistant materials are available today that are more flame resistant than required by NHTSA’s standard. This letter further explained that in addition to the flammability standards approved at the 1990 National Conference on School Transportation, there are guidelines available from the Federal Transit Administration for the flammability of materials inside urban transit buses. States are free to impose a more stringent standard for flammability than currently required by FMVSS no. 302. Enclosed is a copy of the letter for your information. In response to the Board's concerns, NHTSA upgraded the emergency exit requirements for school buses to require additional emergency exits in November 1992. NHTSA believes that the upgraded emergency exit requirements for school buses allow for faster evacuation times in catastrophic crashes and reduce the need to upgrade the flammability requirements for school bus seats. Emergency exits work in many different crash scenarios, while reducing the flammability only slows the rate that a fire propagates. Fires are involved in less than 0.05 percent of all bus crashes. Thus, upgrading flammability requirements would result in a redundant solution to an extremely rare problem with very high costs with little or no corresponding benefit.

From: NHTSA
To: NTSB
Date: 7/12/1996
Response: -From Ricardo Martinez, Administrator: The National Highway Traffic Safety Administration (NHTSA) wishes to thank the Safety Board for closing NTSB Safety Recommendation H-89-6 which asked the agency to evaluate the merits of relocating fuel tanks or provide additional structure to protect the fuel system on school buses. In your letter dated May 15, 1996, you gave Safety Recommendation H-89-4 an "Open--Unacceptable Action" status. This safety recommendation was related to the 1988 church bus crash near Carrollton, Kentucky. Safety Recommendation H-89-4 requested that NHTSA incorporate into Federal Motor Vehicle Safety standard No. 302, Flammability of Interior Materials, the recommendations of the National Institute of standards and Technology concerning the new material acceptance criteria to reduce the rate of fire spread in all buses. In November 1992, NHTSA upgraded emergency exit requirements for school buses. The upgraded emergency exit requirements for school buses allow for faster evacuation times in catastrophic crashes and reduce the need to upgrade the flammability requirements for school bus seats. Thus, upgrading flammability requirements would result in an alternative solution to an extremely rare problem with very high costs with little or no corresponding benefit. our records indicate that this was the only event where there were fatalities caused by fire in a school bus body type vehicle. Emergency exits work in many different accident scenarios, while reducing the flammability only slows the rate that a fire propagates. Fires are involved in less than 0.05 percent of all bus accidents. There is no assurance that upgrading the flammability of school bus seats would have any affect on the outcome of a fuel-fed fire such as in the Carrollton, Kentucky church bus crash. This is apparent since the MARC train accident in Silver Spring, Maryland. This railroad passenger car met the enhanced flammability guideline of the Federal Railroad Administration. The enhanced flammability guideline is based on the Federal Transit Administration guideline for transit buses and yet the car was quickly consumed by flames. Additional emergency exits would have allowed more of the victims to escape the fire. Because the Carrollton bus did not meet the current stringent fuel system integrity requirement, and in light of our issuance of an enhanced emergency exit requirement for school buses, NHTSA requests that the Safety Board reconsider its position on Safety Recommendation H-89-4.

From: NTSB
To: NHTSA
Date: 5/15/1996
Response: The National Transportation Safety Board has reviewed your October 20, 1995, letter in response to Safety Recommendations H-89-4 and -6 which, were issued to the National Highway Traffic Safety Administration (NHTSA) following the Safety Board's investigation of the church activity bus crash near Carrollton, Kentucky, on May 14, 1988. Safety Recommendation H-89-4 asked NHTSA to incorporate in Federal Motor Vehicle Safety Standard (FMVSS) 302 the recommendations of the National Institute of Standards and Technology concerning the new material acceptance criteria to reduce the rate of fire spread in all buses. The Safety Board notes that in November 1992, NHTSA upgraded emergency exit requirements for school buses to allow faster evacuation in catastrophic crashes. However, these requirements do not reduce the need to upgrade the flammability requirements for school bus seats. The Carrollton accident is an example of the potential for deaths and injuries during school bus fires. The Safety Board is disappointed that NHTSA has taken more than 6 years to research this important safety issue without increasing the flammability requirements for materials used in school bus seats. The Safety Board urges NHTSA to utilize the existing research regarding this issue and include in the FMVSS the recommendations of the National Institute of Standards and Technology. Pending further response, Safety Recommendation H-89-4 will remain in an OPEN—UNACCEPTABLE RESPONSE status. Safety Recommendation H-89-6 urged NHTSA to revise FMVSS 301 to provide additional protection for school buses in severe crash situations based on an evaluation of the merits of relocating fuel tanks, providing additional structure to protect fuel system components, and using frangible valves in critical locations. The Safety Board notes that NHTSA has published several advance notices of proposed rulemaking for possible amendments to FMVSS 301, Fuel System Integrity. Although no revisions to FMVSS 301 have been made, we understand that school bus manufacturers generally comply with the regulation's stringent crash test requirements for large school bus fuel systems by adding a cage around the fuel tank. Based on this information, Safety Recommendation H-89-6 has been classified "Closed--Acceptable Action."

From: NHTSA
To: NTSB
Date: 10/20/1995
Response: -From Ricardo Martinez, Administrator: In your letter dated June 23, 1995, you requested additional information on Safety Recommendations H-89-4 and H-89-6. Both of these safety recommendations were related to the 1988 church bus crash near Carrollton, Kentucky. Safety Recommendation H-89-4 requested that NHTSA incorporate into Federal Motor Vehicle Safety Standard (FMVSS) No. 302, Flammability of Interior Materials, the recommendations of the National Institute of Standards and Technology (NIST) concerning the new material acceptance criteria to reduce the rate of fire spread in all buses. Safety Recommendation H-89-6 requested NHTSA to revise FMVSS No. 301, Fuel System Integrity, to provide additional protection for school buses in severe crash situations based on an evaluation of the merits of relocating fuel tanks, providing additional structure to protect fuel system components, and using frangible valves in critical locations. In November 1988, NHTSA issued an Advance Notice of Proposed Rulemaking (ANPRM), announcing its plans to consider upgrading FMVSS 302 for all large buses, including school buses. The commenters generally agreed that measures could be taken to increase the flammability resistance of materials used in school bus seats. In January 1989, the agency commissioned the Center for Fire Research of NIST to conduct research on the flammability resistance of various school bus seat assemblies. It is this research that NTSB recommended we implement upon its completion. In July 1990, NIST published its findings. The report identified the important risk factors associated with fire. However, many issues about the feasibility and details of a test procedure remained unsolved, and NIST recommended that additional research be conducted. The fatalities from the Carrollton, Kentucky, bus crash are the only known fatalities since NHTSA has been collecting data where fire was the primary cause of death in a school bus type vehicle. Most commenters to the NHTSA rulemakings believed that upgrading the standard would result in a significant cost increase for school buses. The cost increase estimates ranged from $275 to upgrade only the seat foam to $1500 for the seat foam and a flame retardant cover for a typical 66-passenger school bus. In November 1992, NHTSA upgraded emergency exit requirements for school buses. These additional emergency exits will allow for faster evacuation in emergencies. Thus, upgrading flammability requirements would result in an alternative solution to an extremely rare problem with very high costs with little or no corresponding benefit. NHTSA believes that the upgraded emergency exit requirements for school buses allow for faster evacuation times in catastrophic crashes and reduce the need to upgrade the flammability requirements for school bus seats. However, NHTSA has written to each State Director of Pupil Transportation and each school bus manufacturer informing them that flame resistant materials are available today that are more flame resistant than required by NHTSA's standard (enclosed). This letter further explains that in addition to the flammability standards approved at the 1990 National Conference on School Transportation, there are guidelines available from the Federal Transit Administration for the flammability of materials inside urban transit buses. States are free to impose a more stringent standard for flammability than currently required by FMVSS No. 302. NHTSA recommends that Safety Recommendation H-89-4 be closed. on March 30, 1989, NHTSA published an ANPRM for possible amendments to FMVSS No. 301 for buses and school buses. The commenters generally agreed that the present requirements in FMVSS No. 301 were adequate. In November 1990, NHTSA issued a report titled "Motor Vehicle Fires In Traffic Crashes." The report indicated that data were insufficient to develop reliable estimates of the effect of FMVSS No. 301 requirements for large school buses. On April 12, 1995, NHTSA published an ANPRM proposing amendments for vehicles with 10,000 pounds gross vehicle weight rating (GVWR) or less. Any action taking place as a result of this will apply to small school buses. The bus involved in the Carrollton, Kentucky, crash was a school bus with a gross vehicle weight rating over 10,000 pounds, manufactured before April 1, 1977, when FMVSS NO. 301 imposed stringent crash test requirements for large school bus fuel systems. Manufacturers generally comply with these requirements by adding a cage around the fuel tank. School buses are the only vehicles with a GVWR over 10,000 pounds that are regulated by the standard. The test is one of the most stringent tests imposed on any vehicle. It involves performing a dynamic test at 30 miles per hour with a rigid faced barrier into the school bus fuel system at any point and angle. It was inconclusive as to whether a cage around the fuel tank would have prevented the fuel tank from rupturing in the bus involved in the Carrollton, Kentucky, crash. Our records indicate that this was the only event where there were fatalities caused by fire in a school bus body type vehicle. Because of this, and the fact that the Carrollton bus did not meet the current stringent fuel system integrity requirement and our issuance of an enhanced emergency exit requirement, NHTSA recommends that Safety Recommendation H-89-6 be closed.

From: NHTSA
To: NTSB
Date: 5/31/1994
Response:

From: NTSB
To: NHTSA
Date: 2/19/1993
Response:

From: NTSB
To: NHTSA
Date: 10/22/1991
Response: Safety Recommendation H-89-4 requested the NHTSA to incorporate in Federal Motor Vehicle Safety Standard (FMVSS) 302 the recommendations of the National Institute of Standards and Technology concerning the new material acceptance criteria to reduce the rate of fire spread in all buses. The Safety Board notes that the NHTSA has issued an Advance Notice of Proposed Rulemaking on school bus flammability, and we have stated in our response to the proposed rulemaking that NHTSA should upgrade the existing regulations for flammability even though a consensus has not been reached on tenability limits. This notice comprises one part of your agency 1 s effort to assess and to amend the FMVSS as they apply to the crash avoidance capabilities, crashworthiness, and postcrash performance of school buses. Safety Recommendation H-89-4 will be held in an "Open--Acceptable Response" status pending further action taken by NHTSA as a result of its review of comments received related to school bus flammability.

From: NHTSA
To: NTSB
Date: 4/11/1991
Response: -From Jerry Ralph Curry, Administrator: A final contract report has been received from the National Institute of Standards & Technology, Center for Fire Research, on the work they performed in assessing the fire performance of interior materials used in school buses. Based on that report & comments received in response to the 11/4/88 Advance Notice of Proposed Rulemaking on school bus flammability, the agency issued a request for comments for a number of issues related to flammability of school buses. A copy of the 2/26/91 Federal Register is enclosed.

From: NTSB
To: NHTSA
Date: 10/18/1989
Response: Thank you for your August 16, 1989, response to the National Transportation Safety Board's Safety Recommendations H-89-4 through -6 which were issued to the National Highway Traffic Safety Administration (NHTSA) following our investigation of the Carrollton, Kentucky church activity bus crash. These three safety recommendations address the need for regulatory revisions in the areas of school bus interior flammability, increased egress capability, and fuel system component protection. The Safety Board has been aware of the extensive work already accomplished through the issuance of advance notices of proposed rulemaking regarding these issues. The Safety Board recognizes these notices as integral parts of the NHTSA's comprehensive effort to assess the need to amend safety standards relating to the crashworthiness and postcrash performance of school buses. We look forward to receiving a further response concerning the NHTSA effort to amend Federal Motor Vehicle Safety Standards 217, 301, and 302. Pending a further discussion of these highway safety issues, Safety Recommendations H-89-4 through -6 will be classified as OPEN—ACCEPTABLE ACTION.

From: NHTSA
To: NTSB
Date: 8/16/1989
Response: From Jeffrey R. Miller, Acting Administrator: Enclosed are copies of Advance Notices of Proposed Rulemaking that were issued prior to the Board's findings. These ANPRMs specifically address the issues concerning the Federal Motor Vehicle Safety Standards covered by the recommendations. Additionally, for recommendation H-89-4, the interagency agreement with the National Institute of Standards and Technology is scheduled for completion in December 1989. The results of their work should provide the Agency with the necessary information to evaluate current and possible new test procedures and test criteria for the flammability of interior materials on buses. We believe that the ANPRMs and interagency agreement with NIST are important steps toward updating school bus safety standards and trust that the board will find our actions responsive to its recommendations.

From: NTSB
To: NHTSA
Date:
Response: At the 1990 Board meeting addressing the NTSB’s Most Wanted List of Transportation Safety Improvements (MWL), the Board voted to place Safety Recommendations H-89-01, H-89-04 through H-89-06, and H-90-74 on the state MWL under the issue category “School Bus Safety.” This category was removed from the MWL in 1998.