2005 — Sep 23, Nursing Home Evacuee’s Bus Burns, Hurricane Rita, TX — 23

lornajarrettblanchard September 23, 2005

— 23 NFPA. “Multiple-Death Fires for 2005.” NFPA Journal, September/October 2006.

— 23 NTSB. HAR. Motorcoach Fire…During Hurricane Rita Evac…Wilmer, TX, Sep 23, 2005.

— 23 Rosenker. “Testimony…Rosenker, Chairman NTSB Before…Senate, Apr 19, 2007.

Narrative Information

NTSB: “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.

“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 post trip 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.” (NTSB. HAR. Motorcoach Fire…During Hurricane Rita Evac…Wilmer, TX, Sep 23, 2005.)

Rosenker: “…on September 23, 2005, a fire engulfed a motorcoach being operated by Global Limo Inc. The bus was carrying 44 residents and staff from an assisted-living facility in Bellaire, Texas away from the predicted path of Hurricane Rita near Houston, Texas, many of which were not ambulatory. Twenty-three elderly passengers were unable to escape the fire and died.

“Our investigation revealed that Global Limo Inc. was in violation of several safety regulations before the accident. For example, the company did not ensure that their drivers were properly licensed to drive motorcoaches and also did not retain vehicle maintenance and repair records as required by Federal Motor Carrier Safety Regulations (FMCSRs). In addition, there was no maintenance program to properly service the vehicle. The lack of such a program directly contributed to this catastrophic fire and loss of life.

“Also contributing to the accident was the Federal Motor Carrier Safety Administration’s (FMCSA) ineffective compliance review system, which provided inadequate safety oversight of this passenger motor carrier. The Board concluded that FMCSA’s current process does not effectively identify unsafe motor carriers and prevent them from operating. In fact, despite many driver and vehicle safety violations, FMCSA had rated Global as “satisfactory” prior to the accident. The Board reiterated its long-standing recommendation to FMCSA to change the safety fitness rating methodology so that either adverse vehicle or driver performance problems alone are sufficient to result in an overall unsatisfactory rating for a carrier.

“As a result of its investigation, the Board made a number of recommendations to the NHTSA to develop a fire protection standard for motorcoach fuel systems, and develop fire detection systems to monitor the temperature of wheel well compartments. We also asked FMCSA to continue to gather and evaluate information on the causes, frequency and severity of bus and motorcoach fires, and conduct ongoing analysis of that data. Finally, the Safety Board asked NHTSA to evaluate motorcoach emergency evacuation designs by conducting simulation studies and evacuation drills.” (Rosenker 2007)

Brubaker: “The cause of the bus fire in Texas has not been determined, though investigators are focusing on the right rear brakes, according to a local law enforcement official. Oxygen canisters used on the bus by some evacuees — and also stored in the baggage compartment — fueled the flames.” (Brubaker Oct 18, 2005)

NFPA: “Following evacuation orders, a nursing home in Bellaire , Texas (in the Houston area) prepared. Families picked up most of the residents, but two busloads of residents and staff members were dispatched to sister facilities in Dallas. One bus loaded with 38 patients and 6 health care workers left the nursing home at 3 PM. On board the bus were two patients using oxygen, 18 oxygen cylinders, wheelchairs, and walkers were stored below the passenger compartment. The second bus departed a short time later. Gridlocked highways turned the four-hour trip into a 15-hour to 16-hour ordeal.

“Between 4 AM and 6 AM on September 23, one bus had a flat right rear tire and the driver pulled off the road. He called for assistance and the tire was fixed. Once on the road, at 6:08 AM, a passerby flagged down the bus driver by pulling in front of the bus and slowing down, at which time another passerby informed the bus driver that the bus was on fire. In his rear-view mirror, the driver saw fire coming from the right rear wheel well. He pulled over and exited the bus to examine the situation. Then, he, the health-care workers and several passersby started to evacuate the patients. The oxygen cylinders exploded and fire spread very rapidly. Tragically, 23 of the 38 patients died in the blaze, and many of the survivors were injured.” (NFPA. “Multiple-Death Fires for 2005.” NFPA Journal, September/October 2006.)

Sources

National Fire Protection Association. “Multiple-Death Fires for 2005.” NFPA Journal, September/October 2006. Accessed at: http://www.nfpa.org/publicJournalDetail.asp?categoryID=1301&itemID=29867&src=NFPAJournal

National Transportation Safety Board. Highway Accident Report. Motorcoach Fire on Interstate 45 During Hurricane Rita Evacuation Near Wilmer, Texas, September 23, 2005 (NTSB HAR-07/01; NTIS PB2007-916202). Washington, DC: NTSB, adopted February 21, 2007, 142 pages. Accessed at: http://www.ntsb.gov/publictn/2007/HAR0701.pdf

Rosenker, Mark V. “Testimony of Mark V. Rosenker, Chairman National Transportation Safety Board Before The Committee on Appropriations, Subcommittee on Transportation, HUD, and Related Agencies, U.S. Senate, 4-19-2007.” Washington, DC: NTSB. Accessed at: http://www.ntsb.gov/speeches/rosenker/mvr070419.htm