Hazardous Materials Accident Report

Release and Ignition of Hydrogen Following

Collision of a Tractor-Semitrailer

with Horizontally Mounted Cylinders

and a Pickup Truck near

Ramona, Oklahoma

May 1, 2001

National 

Transportation 

Safety Board

Washington, D.C.

A

A

N TION

L TRA SPOR

ATIO

N

B OARD

SAF E T Y

N

T

E PLURIBUS UNUM 

NTSB/HZM-02/02

PB2002-917003

Hazardous Materials 

Accident Report

Release and Ignition of Hydrogen Following 

Collision of a Tractor-Semitrailer 

with Horizontally Mounted Cylinders 

and a Pickup Truck near 

Ramona, Oklahoma 

May 1, 2001

NTSB/HZM-02/02

PB2002-917003 National Transportation Safety Board

Notation 7371A 490 LíEnfant Plaza, S.W.

Adopted September 17, 2002 Washington, D.C. 20594
National Transportation Safety Board. 2002. Release and Ignition of Hydrogen Following Collision of

a Tractor-Semitrailer with Horizontally Mounted Cylinders and a Pickup Truck near Ramona,

Oklahoma, May 1, 2001. Hazardous Materials Accident Report NTSB/HZM-02/02. Washington, DC.

Abstract: On May 1, 2001, a tractor-semitrailer that had horizontally mounted cylinders filled with

compressed hydrogen struck a pickup truck near Ramona, Oklahoma. According to witnesses, the tractorsemitrailer then went out of control and overturned while continuing along the highway. It went off the

road to the east and traveled 300 more feet before it stopped. During the process, some of its cylinders,

valves, piping, and fittings were damaged and released hydrogen.. 

The safety issues discussed in this report are the adequacy of Federal requirements for protecting cylinders

that are horizontally mounted on semitrailers and the valves, piping, and fittings of the cylinders during

rollover accidents and the adequacy of the information in the North American Emergency Response

Guidebook about compressed hydrogen

As a result of its investigation of this accident, the Safety Board made recommendations to the Research

and Special Programs Administration.

The National Transportation Safety Board is an independent Federal agency dedicated to promoting aviation, railroad, highway, marine,

pipeline, and hazardous materials safety. Established in 1967, the agency is mandated by Congress through the Independent Safety Board

Act of 1974 to investigate transportation accidents, determine the probable causes of the accidents, issue safety recommendations, study

transportation safety issues, and evaluate the safety effectiveness of government agencies involved in transportation. The Safety Board

makes public its actions and decisions through accident reports, safety studies, special investigation reports, safety recommendations, and

statistical reviews.

Recent publications are available in their entirety on the Web at <http://www.ntsb.gov>. Other information about available publications also

may be obtained from the Web site or by contacting:

National Transportation Safety Board

Public Inquiries Section, RE-51

490 LíEnfant Plaza, S.W.

Washington, D.C. 20594

(800) 877-6799 or (202) 314-6551

Safety Board publications may be purchased, by individual copy or by subscription, from the National Technical Information Service. To

purchase this publication, order report number PB2002-917003 from:

National Technical Information Service

5285 Port Royal Road

Springfield, Virginia 22161

(800) 553-6847 or (703) 605-6000

The Independent Safety Board Act, as codified at 49 U.S.C. Section 1154(b), precludes the admission into evidence or use of Board reports

related to an incident or accident in a civil action for damages resulting from a matter mentioned in the report. 
iii Hazardous Materials Accident Report

Contents

Executive Summary . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . v

Factual Information . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1

Synopsis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1

The Accident . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1

 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4

Emergency Response . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5

Injuries . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8

Meteorological Information . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8

Damage . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8

Pickup Truck . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8

Tractor-Semitrailer . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9

Semitrailer and Cylinder Information . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12

Semitrailer . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12

Cylinders . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13

Hazardous Material Information . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14

Personnel Information . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15

Tractor-Semitrailer Driver . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15

Pickup Driver . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 16

Roadway Information . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17

Motor Carrier Information . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17

Federal Regulations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 18

Protection of Valves, Piping, Fittings, and Cylinders . . . . . . . . . . . . . . . . . . . . . . . . . . . 18

Industry Practices and Interpretations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 18

Emergency Response Preparedness . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19

Postaccident Assessment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19

Training . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19

Postaccident Actions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 20

North American Emergency Response Guidebook . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 20

Analysis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 22

Exclusions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 22

The Accident . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 22

Driver Performance . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 23

Pickup Driver . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 23

Truckdriver . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 23

Performance of Cylinders, Valves, Piping, and Fittings . . . . . . . . . . . . . . . . . . . . . . . . . . . . 24

Damage to Valves, Piping, and Fittings . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 24

Fracture and Ejection of Cylinder 3 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 25

Standards for Cylinders Horizontally Mounted on Semitrailers . . . . . . . . . . . . . . . . . . . . . 25

Emergency Response . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 26

Emergency Response Guidance . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 27

Conclusions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 28

Findings . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 28
Contents iv Hazardous Materials Accident Report

Probable Cause . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 29

Recommendations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 30

Appendixes

A: Investigation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 31

B: Emergency Response Timeline . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 32

C: Safety Recommendations Issued as a Result of Highway Accident 

 Report NTSB/HAR-01/01 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 34
v Hazardous Materials Accident Report

Executive Summary

About 2:15 p.m., central daylight time, on May 1, 2001, a northbound tractor, in

combination with a semitrailer that had horizontally mounted cylinders filled with

compressed hydrogen, which is a flammable gas, struck a northbound pickup truck that

had veered in front of the tractor-semitrailer on U.S. Highway 75, 2 miles south of

Ramona, Oklahoma. According to witnesses, the tractor-semitrailer then went out of

control and overturned while continuing along the highway. It went off the road to the east

and traveled 300 more feet before it stopped. During the process, some of the cylinders,

valves, piping, and fittings at the rear of the semitrailer were damaged and released

hydrogen. The hydrogen ignited and burned the rear of the semitrailer. In the meantime,

the pickup truck had also run off the road. The pickup truckís fuel line ruptured, resulting

in the truck being destroyed by fire. 

As a result of the accident, the truckdriver was killed, and the driver of the pickup

truck was seriously injured. Residents of five homes in the vicinity of the accident were

asked to evacuate, and the highway was closed for more than 12 hours. Damage, cleanup,

and lost revenues were estimated at $155,000.

The National Transportation Safety Board determines that the probable cause of

the May 1, 2001, collision and subsequent fire involving a tractor-semitrailer and a pickup

truck in Ramona, Oklahoma, was the failure, for unknown reasons, of the pickup driver to

control her vehicle. Contributing to the severity of the accident were the inadequate

protection and shielding of the cylinders, valves, piping, and fittings and the inadequate

securement of cylinders on the semitrailer.

This report discusses the following safety issues:

ï The adequacy of Federal requirements for protecting cylinders that are

horizontally mounted on semitrailers and the valves, piping, and fittings of the

cylinders during rollover accidents.

ï The adequacy of the information in the North American Emergency Response

Guidebook about compressed hydrogen.

As a result of its investigation of this accident, the Safety Board makes

recommendations to the Research and Special Programs Administration. 

1 Hazardous Materials Accident Report

Factual Information

Synopsis 

About 2:15 p.m., central daylight time,1 on May 1, 2001, a northbound tractor, in

combination with a flatbed semitrailer that had horizontally mounted cylinders filled with

compressed hydrogen, which is a flammable gas, struck a northbound pickup truck that

had veered in front of the tractor-semitrailer on U.S. Highway 75, 2 miles south of

Ramona, Oklahoma. According to witnesses, the tractor-semitrailer then went out of

control and overturned, while continuing along the highway. It went off the road to the

east and traveled 300 more feet before it stopped. During the process, some of the

cylinders, valves, piping, and fittings at the rear of the semitrailer were damaged and

released hydrogen. The hydrogen ignited and burned the rear of the semitrailer. In the

meantime, the pickup truck had also run off the road. The pickup truckís fuel line

ruptured, resulting in the truck being destroyed by fire. 

As a result of the accident, the driver of the tractor-semitrailer (the truckdriver)

was killed, and the driver of the pickup truck was seriously injured. Residents of five

homes in the vicinity of the accident were asked to evacuate, and the highway was closed

for more than 12 hours. Damage, cleanup, and lost revenues were estimated at $155,000.

The Accident

The tractor-semitrailer was operated by Airgas Mid-South, headquartered in Tulsa,

Oklahoma. The semitrailer carried 10 horizontally mounted cylinders (see figure 1)

loaded with compressed hydrogen. Each cylinder was about 22 inches in diameter and

about 37 1/2 feet long. Combined, the cylinders contained a total of approximately

141,365 cubic feet2

 of hydrogen; each cylinder was pressurized to about 2,500 pounds per

square inch, gauge (psig). The cylinders were secured between two bulkheads and arranged

in three rows; the first (bottom) and second rows each had four cylinders, and the third (top

row) had two cylinders. The cylinders had been filled with hydrogen on April 30, 2001, at

the Airgas Mid-South facility in Tulsa. 

1 All times in this report are central daylight time.

2 At a temperature of 70° F and at 1 atmosphere of pressure.
Factual Information 2 Hazardous Materials Accident Report

The truckdriver departed the Airgas Mid-South terminal in Tulsa about 1:50 p.m.

on May 1, 2001, destined for the Phillips Petroleum plant in Bartlesville, Oklahoma, a

distance of about 45 miles. (See figure 2.) According to witnesses, minutes before the

accident, the tractor-semitrailer was traveling about 65 to 70 mph3 in the left lane of the

four-lane divided highway. Ahead of the tractor in the right lane was a 1983 Chevrolet

pickup truck. According to some witnesses who had followed the pickup truck for a half

mile in the minutes preceding the accident, the pickup truck moved slowly from the right

northbound lane to the left northbound lane of the divided highway, where it almost struck

another vehicle. (One witness said that he believed the driver had fallen asleep but that

when he pulled alongside the pickup truck, he noted that she [the driver] seemed to be

awake.) 

Figure 1. Mounting and cylinder configuration of the accident semitrailer. 

3 The posted speed limit for U.S. Highway 75 in the vicinity of the accident was 70 mph.

7 8 9 10

3 4 5 6

1 2

Cylinders

Rear Bulkhead

Metal straps (Banding)

Forward Bulkhead

Metal

Cabinet
Factual Information 3 Hazardous Materials Accident Report

Witnesses said the pickup truck next swerved from the left lane, through the right

lane, and onto the right shoulder of the highway, where it struck a one-way traffic sign.

(See figure 3.) After striking the sign, the pickup truck veered back onto the highway, into

the left lane and into the path of the tractor-semitrailer. The right front of the tractor struck

the front left axle of the pickup truck. 

Witnesses said the truckdriver appeared to be operating his vehicle normally

before the accident. Witnesses stated that the truckdriver could not have avoided hitting

the pickup truck. 

After the collision, the pickup truck traveled about 365 feet before coming to rest

against a fence and facing south. The tractor-semitrailer remained coupled and traveled

about 210 feet along the roadway beyond the point where it had hit the pickup truck. The

tractor-semitrailer rolled over onto its left side before leaving the roadway. The

tractor-semitrailer left the road and traveled about 300 feet on the embankment before

coming to rest. The tractor and the semitrailer remained coupled with the tractor upside

down and the semitrailer on its right side (the tractor had rolled about 180 degrees, and the

semitrailer had rolled about 270 degrees). One cylinder, cylinder 3, had separated from the

semitrailer and came to rest about 53 feet away. 

Figure 2. Accident location.

Accident

Site

I-40

I-44

I-35

US Hwy

75

Oklahoma City

Bartlesville

Tulsa

Ramona
Factual Information 4 Hazardous Materials Accident Report

Figure 3. Accident diagram.

1

1

2

2

2

2

1

US Highway 75

One Way Sign

Tractor leaning 

w/trailer in the 

process of 

rolling over 

on its left side

Tractor upside down

w/trailer on its right side

160’

146’

82’

210’

365’

300’

One Way Sign

Fence

1

2

 Pickup Truck

 Tractor-semitrailer

Not to scale

N

Cylinder

Dirt Road

1

92’

53’
Factual Information 5 Hazardous Materials Accident Report

Emergency Response4

The Washington County, Oklahoma, 911 Center received numerous telephone

calls at 2:15 p.m. reporting a traffic accident on U.S. 75 involving a tractor-semitrailer,

explosions, and fires. Members of the Ramona volunteer fire department were dispatched

to the scene. The chief of the department arrived on scene about 2:22 p.m. and assumed

incident command. Before the emergency response personnel arrived, witnesses had

already extricated the pickup driver from her vehicle through the passenger door. (At

3:12 p.m., an ambulance took her to St. Francis Hospital in Tulsa, Oklahoma.) 

Just after the accident occurred, an Airgas Mid-South employee passed the

accident and notified the company that one of its semitrailers with horizontally mounted

cylinders was involved. In response, Airgas Mid-Southís president, vice president, and

safety director came to the scene, arriving at 3:20 p.m. 

By 2:16 p.m., the Washington County Emergency Management director (the

director) was en route to the accident scene and was advised by the Washington County

Sheriff dispatcher that ìsome type of tanker was involved, possibly hydrogen.î At

2:21 p.m., via radio, the director asked the Phillips Petroleum dependable accident

response team (DART)5

 to come to the scene. (It arrived within 15 minutes.) At 2:22 p.m.,

also via radio, he told the Ramona fire department responders that the cylinders might be

pressurized and asked the volunteer fire departments from surrounding areas for mutual

aid.6 Members of volunteer fire departments from the towns of Ochelata and Oglesby

arrived shortly afterward. 

The Ramona, Oglesby, and Ochelata fire departments initially staged their vehicles

and personnel in the northbound lanes of U.S. 75, approximately 40 feet west of the

overturned tractor-semitrailer and in a direct line with the forward ends of the cylinders.

The vegetation that surrounded the rear of the semitrailer was burning, as were the rear

tires of the semitrailer.

While the director was traveling to the scene, the Washington County assistant fire

chief, who was at the fire station, read the information about hydrogen in the 1996 North

American Emergency Response Guidebook7

 to the director by radio. At 2:25 p.m., while

the director was still en route, he activated the Washington County Emergency Operations

4 Refer to appendix B for a timeline of significant emergency response events.

5 The Phillips Petroleum DART gave technical assistance in the early stages of the incident to the

director. This was done in accordance with a mutual aid agreement for the DART to provide hazardous

materials assistance when needed to Washington County. DART also provided two unmanned ground water

monitors that were used in the latter stages of the emergency response to spray water on the cylinders. 

6 A total of nine fire departments from the surrounding communities responded to the mutual aid call.

7 The guidebook is used to aid first responders in quickly identifying the specific or generic hazards of

materials involved in hazardous materials incidents. It is published every 4 years through the cooperation of

the U.S. Department of Transportation, Transport Canada, and Mexicoís Secretariat of Communications and

Transport. The latest edition was published in 2000.
Factual Information 6 Hazardous Materials Accident Report

 Center and the Washington County Emergency Operations Plan.8 At 2:30 p.m., he

arrived on scene and assumed incident command from the Ramona fire department chief.

By that time, the Ramona fire department had already started spraying water from several

handlines on the burning vegetation and on the rear of the semitrailer. 

At the same time, members of the Ochelata and Oglesby fire departments were

attempting to extricate the truckdriver from the overturned and crushed tractor. He was

trapped in his tractor, which was within 15 feet of the forward ends of the cylinders.

According to the director, when he arrived on scene, firefighters had already made an

initial medical assessment of the truckdriver. They said that they had detected a ìpossible

weak or faint pulseî and thought the area was safe enough to extricate the driver. 

At 2:35 p.m., after an initial on-scene assessment, the director decided to establish

a defensive operation only and told the firefighters to spray significant amounts of water

on the cylinders, ìbut only from a distance.î Also at 2:35 p.m., the shift superintendent of

the Phillips Petroleum DART arrived and told the firefighters to stay away from the ends

of the cylinders. They took firefighting positions on both sides of the semitrailer and tried

to avoid the ends of the cylinders. However, the emergency response vehicles that were

being used to spray water were not moved away from the ends of the cylinders for another

hour. 

At 2:40 p.m., the effort to extricate the truckdriver was stopped, pending the

delivery of additional water to continue cooling the cylinders. By 2:55 p.m., the water had

arrived, and more handlines were deployed to maintain cooling streams on the cylinders.

By 3:15 p.m., members of the Ochelata and Oglesby fire departments had extricated the

truckdriver. Because no pulse was found, he was taken by ambulance to the medical

examinerís facility in Jane Phillips Hospital, Bartlesville, Oklahoma. 

In the meantime, between 2:30 and 3:11 p.m., an Oklahoma Highway Patrol

officer trained in hazardous materials arrived. At 3:11 p.m., he requested, on his own

initiative, the assistance of the Tulsa fire departmentís hazardous materials response team

(the Tulsa hazardous materials team). At approximately 3:30 p.m., the first of 6 units and

17 firefighters from the Tulsa hazardous materials team arrived, as well as a pumper truck

from the Bartlesville fire department. 

About 3:35 p.m., the chief of the Tulsa hazardous materials team formally

assumed command of the incident, after he and the director had agreed on how to evacuate

personnel and equipment to a safer distance. They agreed to use the Bartlesville pumper

truck and unmanned ground monitors to continue cooling operations while personnel left

the area. The chief then directed the firefighters to move away from the scene. He

proceeded to develop an action plan that included moving the fire suppression personnel

across the highway and setting up water shuttles and unmanned monitors. He established a

8 The Washington County Emergency Operations Plan is periodically certified by the Washington

County commissioners, the mayor of Bartlesville, the Oklahoma emergency management planning officer,

and the director. The most recent certification was on March 29, 1999.
Factual Information 7 Hazardous Materials Accident Report

ìhot zoneî perimeter of 300 to 600 feet, a ìwarm zoneî perimeter of 600 to 900 feet, and a

ìcold zoneî perimeter of 1,500 feet.9

 The Tulsa hazardous materials team sent a

reconnaissance team in to survey the condition of the valves on the cylinders and

monitored the temperature of the cylinders.

About 4:00 p.m., the Airgas Mid-South safety director offered the assistance of the

Airgas AERO team10 to the chief of the Tulsa hazardous materials team. At 4:30 p.m., the

safety director activated the AERO team, and it arrived on scene about 5:15 p.m. The

AERO team assisted the firefighters with cooling and monitoring operations. 

About 6:00 p.m., the chief of the Tulsa hazardous materials team and the director

began to discuss releasing the Tulsa fire department units because the accident scene had

been stabilized. About 6:30 p.m., the Tulsa fire department units began demobilizing, and

within 10 minutes, the team departed. 

The director then resumed incident command. By 12:20 a.m. on May 2, all

cylinders had been vented of hydrogen and the fire was out.

At approximately 12:55 a.m., the director left the scene, and the Oklahoma

Highway Patrol assumed incident command. By 1:03 a.m., all fire and rescue units had

left. The Oklahoma Highway Patrol and the AERO team stayed until the highway was

reopened, about 6:00 a.m. 

Injuries

Table 1 is based on the injury criteria of the International Civil Aviation

Organization, which the Safety Board uses in accident reports for all transportation modes.

As a result of the accident, the driver of the pickup truck was seriously injured, and

the truckdriver was killed. According to the Oklahoma Chief Medical Examiner, the

truckdriver had sustained multiple blunt-force traumas. 

9 The establishment of perimeter zones helps ensure that response personnel are properly protected

against the hazards present at a hazardous materials transportation accident. During this accident, the ìhot

zoneî indicated the area where there was the greatest risk of explosion or overpressurization of the

cylinders. The ìwarm zoneî indicated the area where response personnel were staged, and the ìcold zoneî

identified the area from which the general public and media could view the accident scene safely.

10 The Airgas Mid-South AERO (Airgas emergency response organization) team responds to hazardous

materials incidents involving Airgas Mid-South. The team is trained and equipped to handle most cryogenic

and/or compressed gases.
Factual Information 8 Hazardous Materials Accident Report

Table 1. Injuries sustained in Ramona, Oklahoma, accident

Meteorological Information

The weather at the time of the accident was dry; the skies were slightly cloudy; the

visibility was clear; and the temperature was near 84° F. Wind was gusting to about 17

mph from a southwesterly direction.

Damage

Pickup Truck

The pickup truck, a 1983 C-10 model Chevrolet, had sustained extensive impact

and fire damage. The left side of the vehicle, including the front fender, hood, driverís

door, and side of the cargo bed, was badly crushed. The left front fender had been pushed

against the engine. The fire had destroyed the interior of the cab and burned away the

exterior paint on the vehicle. The gas tank fuel line had separated from the fuel tank, and

the tires had burned. 

The steering components were damaged, and the left front wheel and tie rod were

bent. The steering column and steering box had been damaged in the collision and burned

in the fire. Consequently, they could not be inspected for preaccident problems. The brake

lining, drums, and hydraulic lines had also been damaged enough that it was not possible

to examine the brake system for pre-impact defects. Because the vehicle could not be

started, the performance of the engine and related parts could not be evaluated. 

Tractor-Semitrailer

Tractor-Semitrailer. The tractor, a 1999 conventional Freightliner, was badly

crushed. The roof was crushed down to the dashboard. Because of the extensive crushing,

Injuries* Tractor-Semitrailer Pick-up Truck Total

Fatal 1 0 1

Serious 0 1 1

Minor 0 0 0

Total 1 1 2

*49 Code of Federal Regulations 830.2 defines fatal injury as ìany injury which results in death within 30 days of the 

accidentî and serious injury as ìan injury which: (1) requires hospitalization for more than 48 hours, commencing within 

7 days from the date the injury was received; (2) results in a fracture of any bone (except simple fractures of fingers, 

toes, or nose); (3) causes severe hemorrhages, nerve, or tendon damage; (4) involves any internal organ; or (5) 

involves second or third-degree burns, or any burn affecting more than 5 percent of the body surface.î
Factual Information 9 Hazardous Materials Accident Report

the brake system on the tractor could not be fully inspected; however, the chambers and

brake adjustments were checked and were within the manufacturerís readjustment limits.

The data downloaded from the tractorís electronic control unit11 showed no abnormal

codes. The maintenance records for the tractor revealed only routine or expected

maintenance and no known mechanical deficiencies. 

The semitrailer was a 1992 Doonan standard flatbed trailer with a 10-cylinder

hydrogen rack configuration welded to the bed. The semitrailerís frame rails were bent

just forward of the front axle, and the torsion bar for both the front and rear axles was

broken. The rear bumper was bent and twisted in various directions.

Cylinder Mounting and Equipment. Forces involved in the accident had bent

both bulkheads rearward in the area where cylinder 3 (the cylinder ejected from the

semitrailer) had been mounted. The resulting deformation left the two bulkheads about an

inch further apart in this area than they had been designed to be. The paint on the rear

bulkhead had been damaged by the fire. The bands (metal straps) used to secure the

bottom row of cylinders (cylinders 7 through 10) were still intact.

The cabinet, which enclosed the valves, piping, and fittings for the cylinders, had

separated from the rear bulkhead and was crushed inward from the passenger side of the

semitrailer toward the driverís side. (See figure 4a. Figure 4b shows the rear view of a

similar vehicle configuration without damage.) The master valve and the shutoff valves,

piping, and fittings for eight of the cylinders had been sheared off. The valves for the other

two cylinders were intact but broken away from their piping. Both valves were bent in a

direction consistent with the application of a force applied from the right side of the trailer. 

Cylinders. The paint on the rear end of most of the cylinders (cylinders 1, 2, 4, 7,

8, and 9) was sooted and discolored. The sooted area was directly over the rear tires,

which were shredded and burned. The paint on the outboard side of each outside cylinder

(cylinders 1, 2, 3, 6, 7, and 10) was, to varying degrees, scraped along the length of each

cylinder. (See figure 5.) These cylinders extended beyond the envelope formed by the

bulkheads. (Refer to figure 1.) Cylinder 1 also had scraped paint that extended around its

circumference in a 2- to 3-foot-wide strip near the middle of the cylinder. The unpainted

threads at each end of cylinder 1 were also visible. (The unpainted threads cannot be seen

when a cylinder is fully screwed into flanges bolted to the front and rear bulkheads. The

flanges secure the front and rear of the cylinder to the front and rear bulkheads of the

semitrailer.) (See figure 6.) 

11 This is a semiconductor unit for controlling ignition timing and other parameters in an engine

management system.
Factual Information 10 Hazardous Materials Accident Report

Figure 4. Rear view of a typical semitrailer's cabinet without damage. 

Figure 4a. Cabinet after accident; 8 of the 10 

valves have been sheared off.

Damage to piping 

and valves

Remains of Metal Cabinet

Twisted and bent bumper

Vent Lines

Ruptured Disks Master Valve Temperature Probe

Valves for 

each cylinder

Figure 4a. Cabinet after accident; 8 of the 

10 valves have been sheared off.

4b.
Factual Information 11 Hazardous Materials Accident Report

Cylinder 3, which had been ejected from the vehicle, also had circumferential

abrasions. The front neck/shoulder of the cylinder was fractured (see figure 7). The

fracture features and deformation were consistent with an overstress fracture. The threads

on the rear neck of the cylinder and the threads on the rear flange were also damaged, with

off-axis rotational scoring. 

Figure 5. Scrapes on the outboard sides of cylinders on the accident 

semitrailer. 

Figure 6. Unpainted threads of cylinder 1 next to the bulkhead flange. 

Anti-rotation Pin Slots

Bulhead Flange

Cylinder Threads

Cylinder Neck
Factual Information 12 Hazardous Materials Accident Report

Semitrailer and Cylinder Information

Semitrailer

The accident semitrailer had been manufactured in October 1991 by Doonan

Trailer Corporation of Great Bend, Kansas. Doonan had also mounted the cylinders on the

semitrailer. The accident semitrailer was one of seven semitrailers with horizontally

mounted cylinders that Doonan manufactured between the late 1980s and early 1990s for

Brown Welding12 of Salina, Kansas. Doonan no longer produces this type of semitrailer.

Today, four manufacturers13 produce about 80 percent of the semitrailers that have

horizontally mounted cylinders. Between 1998 and 2001, the four manufacturers

produced, on average, a total of about 240 of these semitrailers each year;14 the largest

manufacturer produced 120 annually, and the smallest produced 18. Safety Board

investigators tried to ascertain the number of these semitrailers currently in operation;

however, no government agency or industry organization could provide an accurate

accounting of the operational fleet. 

Figure 7. Cylinder 3's forward end, which has an overstress fracture on 

its shoulder and a spiral crack from the fracture surface into the head of 

cylinder.

12 Airgas purchased Brown Welding in 1999.

13 FIBA Technologies, Inc.; City Machine and Welding; Weldship Corporation; and Western Sales and

Testing.

14 The number includes new semitrailers with used cylinders that have been requalified under

49 CFR 173.34 and new cylinders manufactured overseas.
Factual Information 13 Hazardous Materials Accident Report

Cylinders

The 10 cylinders on the accident semitrailer were U.S. Department of

Transportation (DOT) specification 3AAX cylinders and were manufactured in 1991 by

CP Industries (CPI) of McKeesport, Pennsylvania. All 10 cylinders were certified

acceptable for transporting compressed gases following a postmanufacture inspection

conducted in July 1991 by the Robert W. Hunt Company of Lombard, Illinois, as required

by the DOTís hazardous materials regulations.

CPI manufactures approximately 600 DOT specification 3AAX cylinders

annually. CPI also manufactures about 800 DOT specification 3T cylinders annually. CPI

is the only known domestic manufacturer of specification 3AAX and 3T cylinders. Both

types of cylinders are used to transport virtually the same products and are subject to the

same design and operating requirements under the hazardous materials regulations. The

specification 3AAX cylinder is authorized to transport the following non-liquefied

compressed gases: air, argon, boron trifluoride, carbon monoxide, ethane, ethylene,

helium, hydrogen, methane, neon, nitrogen, and oxygen. The specification 3T cylinder is

authorized to transport all of those gases except hydrogen. Both specifications must be

horizontally mounted on motor vehicles or in an ISO (International Organization of

Standardization) framework.15 The specification 3AAX and 3T cylinders have different

design requirements relating to materials of construction, thickness of the cylinder wall,

and maximum allowable pressure ratings. 

Horizontally mounted cylinders are typically about 37 feet long and 22 inches in

diameter. A single semitrailer carries between 7 and 12 cylinders. Each cylinder on the

accident vehicle had a water capacity of about 87 cubic feet and a minimum wall thickness

of 0.536 inch. 

Both necks of each cylinder on the accident semitrailer had inside and outside

threads. The outside threads were screwed into six-bolt flanges that secured the cylinder to

the bulkheads. Anti-rotation pins were inserted between the flange and the outside threads

of the cylinder. (See figure 8.) Adaptors were screwed into the inside threads of each neck

of each cylinder. The front-end adaptor held a rupture disk,16 whereas the rear-end adapter

held a rupture disk and the shutoff valve for the cylinder. The valves, piping, and fittings at

the rear of the semitrailer allowed the contents of all 10 cylinders to be loaded or unloaded

simultaneously or in a series of one or more. The valves and piping from each cylinder

joined at a master shutoff valve.17 Piping used to release pressure and vent each cylinder

was installed on the front and rear of the semitrailer. 

15 An ISO framework, as it applies to horizontally mounted DOT specification 3AAX and 3T cylinders,

provides a box-like structure around a fixed number of cylinders. This configuration and design provides

structural integrity and support to the cylinders it transports. 

16 Rupture disks are also known as safety disks. They are frangible safety devices that burst and release

built-up pressure so the cylinder would not burst if overpressurized. The rupture disks on the cylinders had a

burst range of 3,700 to 4,000 psig.

17 The piping from each cylinder had a diameter of 3/8 inch, and the vent piping had an outer diameter

of 1 1/8 inches.
Factual Information 14 Hazardous Materials Accident Report

Hazardous Material Information

Hydrogen is a colorless, odorless, highly flammable gas. Hydrogen is a serious fire

hazard when accidentally released. Hydrogen ignites readily in air at any ambient

temperature. It burns with an invisible flame; and because it is less dense than air, it rises

when it is released to the atmosphere. Hydrogen has a lower explosive limit of 4 percent

and an upper explosive limit of 75 percent.18 (For comparison, natural gas has a lower

explosive limit of 3.8 percent and an upper explosive limit of 17 percent.)

Figure 8. Diagram of the rear end of a cylinder, showing how it is secured into a flange, 

which is then secured with bolts to the bulkhead. The valve is screwed into an adapter, 

which is inserted into the end of the cylinder.

18 Lower and upper explosive limits refer to the concentration of a gas in air that will support

combustion. 

Vent Piping

Rupture Disk

Gas Transfer

Rear Bulkhead

Flange

Six Securing Bolts

Anti Rotating Pin

Adapter
Factual Information 15 Hazardous Materials Accident Report

Personnel Information

Tractor-Semitrailer Driver

The truckdriver was a 46-year-old male employee of Airgas Mid-South. He had a

Kansas commercial driverís license with a hazardous materials endorsement that had an

expiration date of November 17, 2003. The Oklahoma Highway Patrol had no record of

violations by the driver.

According to medical records obtained from his personal physician, the

truckdriver was being treated for multiple medical problems, including diabetes (treated

with Actos [pioglitazone], Glucophage [metformin], glyburide, and insulin), chronic neck

pain for which he had been seeking disability (treated with disk surgery and spinal fusion),

and anxiety (treated with Xanax [alprazolam]). His personal physician first prescribed

insulin for him on October 16, 2000, after oral medications alone failed to control his

blood sugar. Insulin and the oral medications that he used may cause side effects,

particularly abnormally low blood sugar (hypoglycemia), which can impair performance.

Common side effects of Xanax include drowsiness and light-headedness; the medication

has also been shown to impair the performance of many cognitive and psychomotor tasks.

A note signed by the driverís personal physician on November 8, 2000, in his

medical records stated that the driverís ìdiabetes has been under great control, and he has

had no problemsî on the prescribed oral medications and insulin. An additional note in his

medical records, which was dated January 31, 2001, indicated that a prescription for

insulin had been called in to the driverís pharmacy and that the driver should ìstay on it.î 

On November 28, 2000, about 5 months before the accident, the driver had had his

most recent required physical examination.19 According to the medical examiner, the

driver told her that he had diabetes and that he was taking three prescribed oral medicines

for diabetes: Actos, Glucophage, and glyburide. He did not tell her that he was taking

insulin for his diabetes. According to DOT motor carrier regulations for commercial

drivers found at 49 CFR 391.41(b)(3), a driver with an ìestablished medical history or

clinical diagnosis of diabetes mellitus currently requiring insulin for controlî cannot be

medically certified.

The medical examiner checked the box on the certification form that indicated that

the driver suffered ìpermanent defect from illness, disease or injury.î She entered the

following on the certification form: ìFusion of C4-C5,î ìType 2 Diabetes,î20 the names of

the three diabetes medications that the driver said he was taking, and ìhealthy male.î She

signed the form that certified the driver was medically qualified to operate a commercial

motor vehicle. 

19 Pursuant to 49 CFR 391.45, all operators of commercial motor vehicles must be medically examined

and certified at least every 2 years.

20 Non-insulin-dependent diabetes mellitus; diabetes mellitus -- Type II.
Factual Information 16 Hazardous Materials Accident Report

A comprehensive toxicology evaluation of the blood specimen obtained during the

driverís autopsy was conducted by the Civil Aeromedical Institute (CAMI), Oklahoma

City, Oklahoma, and was negative for tested drugs, including alcohol, cocaine,

amphetamines, marijuana, phencyclidine, opiates, benzodiazepines, barbiturates,

antidepressants, antihistamines, meprobamate, methaqulaone, and nicotine at established

cutoff values.21 Hemoglobin A1c in the specimen, an indication of blood sugar control,

was minimally elevated.22

Pickup Driver

The pickup driver was 69 years old and had a valid Oklahoma motor vehicle

license with an expiration date of August 2004. Her driving record did not include any

violations, and her license had no operating restrictions.

Her medical records indicated that she was taking prescription medications for

several problems, including diabetes (treated with Glucophage XR [metformin

extended-release] and Glucotrol [glipizide]), hypertension (treated with Tarka

[verapamil/trandolapril]), and anxiety (treated with Triavil [amitriptyline/perphenazine]).

Glucophage XR and Glucotrol are oral medications for diabetes. Side effects may include

abnormally low blood sugar (hypoglycemia), which can impair performance. Tarka is

used to treat high blood pressure. Side effects may include abnormally low blood pressure.

Triavil is typically used by patients with moderate to severe anxiety and depression.

Amitriptyline, a component of Triavil, has sedative effects. Perphenazine, the other

component of Triavil, is an anti-psychotic medication. Triavil may cause tardive

dyskinesia, a condition marked by involuntary muscle spasms and twitches in the face and

body. 

According to the driverís medical records, her blood pressure and blood sugar

were normal on medications. A comprehensive toxicology evaluation of a blood specimen

obtained during her initial medical evaluation after the accident was conducted by the

CAMI and was negative for the following drugs: alcohol, cocaine, amphetamines,

marijuana, phencyclidine, opiates, benzodiazepines, barbiturates, antidepressants,

antihistamines, meprobamate, methaqulaone, and nicotine at established cutoff values.

Hemoglobin A1c in the specimen, an indication of blood sugar control, was normal. 

On May 5, 2001, Safety Board investigators briefly interviewed the driver of the

pickup truck in her hospital room. She was asked to describe the events that led up to the

accident. She stated that she would not have lost control of her pickup truck if the

tractor-trailer had not hit her first. Due to her medical condition and the length of time

required for additional questioning, the investigators later followed up with questions

about the medications she took and her activities during the 3 to 4 days before the

21 These values are the threshold values in μg/ml used to report positive results. Values below these

concentrations are normally reported as not detected.

22 The level reported was 6.8 percent; at the CAMI laboratory, ìlevels above 6% are considered

abnormal.î
Factual Information 17 Hazardous Materials Accident Report

accident. She responded by providing a list of her medications and the name of her

physician, but she did not recall her activities for the 3 to 4 days before the accident.

Roadway Information

U.S. Highway 75, in the vicinity of the collision, was a divided four-lane concrete

roadway running north-south that had a posted speed limit of 70 mph. The paved portion

of the northbound roadway was about 39 feet wide, which included an 11-foot-wide

outside (right) shoulder, two 12-foot-wide traffic lanes, and a 4-foot-wide inside (left)

shoulder. East of the northbound outside shoulder was an earthen embankment with an

approximate slope of 40 percent and an 80-foot easement to the fence line.

The traffic lanes were divided by standard pavement markings, painted white

stripes that were approximately 12 feet long and 30 feet apart. Painted edge lines separated

the traffic lines from the shoulders. A solid white edge line (fog line) ran along the outside

shoulder, and a solid yellow edge line ran along the inside shoulder. The northbound and

southbound portions of the highway were separated by a depressed earthen median. The

part of the median that was directly adjacent to the accident location was about 56 feet

wide.

Motor Carrier Information

Airgas is a national distributor of compressed gases operating at 700 locations

throughout the United States. Airgas Mid-South, which is 1 of 14 regional divisions of

Airgas, employs about 550 people and operates 45 retail/wholesale outlets,23 8

cylinder-filling plants, and 1 ultrasound testing facility in an area that includes western

Missouri, northern Texas, Arkansas, Louisiana, Oklahoma, Kansas, western Mississippi,

and Tennessee.

The company buys hydrogen and other flammable and non-flammable gases from

various suppliers and transports the gases to customers by using either semitrailers with

horizontally mounted cylinders or other vehicles that carry portable cylinders. The

customers may be industrial, medical, manufacturing, or maintenance facilities. Because

Airgas Mid-South is one of a few regional companies to deliver hydrogen, it delivers

hydrogen as far northeast as Michigan and as far west as Phoenix, Arizona. Airgas

Mid-South has 128 regular hydrogen customers and delivers approximately 207 hydrogen

shipments each month by semitrailers with horizontally mounted cylinders. Airgas

Mid-South owns 14 semitrailers with horizontally mounted cylinders and leases an

additional 10. 

23 The company sells industrial, medical, and specialty gases; welding equipment; and safety

equipment and supplies at these locations.
Factual Information 18 Hazardous Materials Accident Report

Federal Regulations 

Protection of Valves, Piping, Fittings, and Cylinders

Under the hazardous materials regulations (49 CFR 173.301(l)(2)), specification

3AAX and 3T cylinders when transported on a motor vehicle or in an ISO framework

must be fixed at one end of the vehicle or framework with ìprovisionî for thermal

expansion at the opposite end attachment. The ìprotective structureî for valves and safety

relief devices for the cylinders must be ìsufficiently strong to withstand a force equal to

twice the weight involved with a safety factor of four, based on the ultimate strength of the

material used.î The regulations do not define the term ìweight involvedî or explicitly

state whether the safety factor is based on the weight of the vehicle or on the ultimate

strength of the material of the protective structure. 

During a postaccident interview with Safety Board investigators on July 12, 2001,

the acting director for the Research and Special Programs Administrationís (RSPAís)

Office of Hazardous Materials Technology defined ìweight involvedî as the weight of the

entire vehicle applied in a single direction from the rear and said that the term does not

include side or vertical forces. He said that the only valve protection requirements

applicable to horizontally mounted cylinders on semitrailers are those in the section cited

above and that the section has not been revised since 1964. He also stated that the cabinet

and rear bumper on a semitrailer provide additional protection and security for the valves

and fittings.

The hazardous materials regulations do not require that horizontally mounted

cylinders also be protected or shielded from the impact damage resulting from a rollover

of the semitrailer. Further, the regulations require only that horizontally mounted cylinders

be secured at both ends of a semitrailer and do not require additional measures to reduce

the likelihood of a cylinder being ejected during a rollover accident. 

Industry Practices and Interpretations

The four manufacturers of semitrailers with horizontally mounted cylinders and

CPI said they knew about the general requirement (49 CFR 173.301) that valves be

protected. One manufacturer stated that the cabinets are designed to protect the valves

from being sheared or broken off. According to another manufacturer, the extension of the

trailer past the rear tires serves as the valve protection, and the cabinet is intended simply

for shielding the valves from inclement weather.

The four manufacturers stated that although they are not required to band cylinders

on semitrailers, all four use banding as an extra precaution to keep the cylinders on the

semitrailer. Three of the four manufacturers stated that they use secondary securing on at

least some of the cylinders on their semitrailers. The fourth manufacturer stated that it

bands all cylinders on its semitrailers. One manufacturer stated that because its bulkheads

are so strong, it bands only the bottom row of cylinders. 
Factual Information 19 Hazardous Materials Accident Report

Emergency Response Preparedness

Postaccident Assessment

The Washington County Emergency Management director stated during

postaccident interviews with Safety Board investigators that when he arrived on scene, he

was troubled by how close the emergency response vehicles were to the burning

semitrailer. He said that the majority of responding vehicles should have been further

away from the tractor and semitrailer. The director believed that the responding vehicles

were positioned in a way that limited their escape route (instead of being backed in, they

had been pulled in front first). He stated that ìbased on the training level of some of the

initial responders, they should have known betterî because some of the firefighters had

been through hazardous materials training. The director said he considered the risks of

breaking down the firefighting equipment and moving all personnel and equipment back

to a safer location. He felt that the scene appeared to be stable and, therefore, decided that

the risks involved in breaking down and repositioning personnel and equipment seemed to

be greater than the risks involved in keeping them in place and maintaining the stability of

the scene. He was concerned that the scene could deteriorate very quickly if the

responders broke down and restaged their equipment. He requested that some of the

responding vehicles (an ambulance, an Oklahoma Highway Patrol car, and his Suburban)

not involved with the firefighting efforts be repositioned to the north. His goal was to

reach the isolation distance given in the guidebook (1 mile in all directions) as quickly as

possible.

Training

According to the director, in Oklahoma, neither State nor county government

imposes formal training requirements on volunteer fire departments. The level of training

for the volunteers ranges from none to level II firefighter, which is the most advanced

course in firefighting offered by Oklahoma State University. A level II firefighter must be

able to (1) determine the need for command, (2) organize and coordinate an incident

management system until command is transferred, and (3) function within a single role in

the incident management system. Such a firefighter is trained in communications, fire

ground operations, rescue operations, prevention, preparedness, and maintenance.

According to the director, most Oklahoma fire departments are beginning to require

volunteer firefighters to complete a course on volunteer firefighting practices that covers

limited interior structural (building) firefighting techniques and is also offered by the

university. 

A majority of volunteer firefighters in Washington County have had hazardous

materials awareness training, which teaches firefighters how to recognize the presence of

hazardous materials and, if possible, to identify them. Some of the firefighters have also

had hazardous materials operations training, which teaches basic hazard and risk

assessment techniques and basic hazardous materials terms. A select few firefighters are

qualified as hazardous materials technicians; they are trained to classify, identify, and

verify known and unknown materials by using field survey instruments and to understand

hazard and risk assessment techniques. According to the director, ìa majority of the
Factual Information 20 Hazardous Materials Accident Report

departments and personnel involved in [this accident] have trained pretty extensively in

comparison to other volunteer departments in the State.î According to his training records,

the director had completed the following relevant courses: Basic Incident Command

System, Evacuation Operations, Hazardous Materials Awareness Instructor, On-Scene

Incident Commander, and Fire Service Instructor I.

On March 17, 2001, about 2 months before the accident, Washington County

Emergency Management held an incident command drill. It was a 4-hour exercise that

involved a controlled burn of a meadow behind Phillips Petroleum. The participating

organizations and agencies included the Phillips Petroleum DART, county fire

departments, and other county emergency management officials. The purpose of the

exercise was to practice the implementation of a unified command structure and the use of

the county emergency operations center.

Postaccident Actions

According to the director, after the accident, Washington County established a

hazardous materials response team. As of May 7, 2002, this team became active on a

limited basis for immediate emergencies. The team is made up of volunteer firefighters

from six area departments. The teamís base is the Washington County Emergency

Operations Center in Bartlesville, Oklahoma. The team has purchased a trailer and a

limited amount of equipment. As a direct result of the Ramona accident and of the terrorist

attacks of September 11, 2001, the county received a $35,000 grant to acquire more

equipment. According to the director, the team will coordinate training on its own

equipment with Oklahoma State University. All the team members have received

hazardous materials operations training, which includes learning how to recognize

hazardous materials; and an unspecified number of team members have received

advanced hazardous materials training. 

Since May 1, 2001, the county has also performed one community-wide drill, in

fall 2001, with the participation of Phillips Petroleum. The scenario involved a chemical

spill and fire resulting in simulated injuries requiring hospitalization and simulated

fatalities. In addition, each volunteer fire department in the county is holding drills within

its department. The Washington County fire department, for example, has had drills on the

use of personal protective equipment. Since November 2001, the county has required each

fire department to complete 3 hours of training in firefighting techniques every month. 

North American Emergency Response Guidebook

According to the North American Emergency Response Guidebook, the book is to

be used by first responders during the initial phase of a hazardous materials incident. The

book states that it ìis primarily a guide to aid first responders in quickly identifying the

specific or generic hazards of the material(s) involved in the incident and protecting

themselves and the general public during the initial response phase of the incident.î The

book explains that it should not be considered a substitute for emergency response

training, knowledge, or sound judgment. 
Factual Information 21 Hazardous Materials Accident Report

The book has 61 different hazardous materials guides that explain initial response

measures for all of the designated classifications of hazardous materials, such as

flammable gases, corrosive materials, and poisons. Each guide provides information about

the potential of fire and/or explosion and about health hazards. Each guide also

recommends appropriate levels of protective equipment for emergency responders,

isolation and evacuation distances, and firefighting and first aid measures.

The guide for hydrogen also applies to other flammable gases, such as liquefied

petroleum gas, and refrigerated liquids, such as compressed trifloroethane (a refrigerant).

The guide for hydrogen recommends that firefighters fight the fires ìfrom a maximum

distanceî or use unmanned hose holders or monitors. The guide does not list some of the

properties that are unique to hydrogen; it does not explain that hydrogen burns with an

invisible flame front and is lighter than air. Other gases to which the guide applies burn

with a visible flame front or are nonflammable, are heavier than air, and sink to the

ground.
22 Hazardous Materials Accident Report

Analysis

This analysis is presented in three main parts. In the first part, the Safety Board

identifies factors that can be readily excluded as causal or contributory to the accident. In

the second part, the Board analyzes the cause of the accident. In the final part, the Board

discusses the safety issues arising from the investigation:

ï The adequacy of Federal requirements for protecting cylinders that are

horizontally mounted on semitrailers and the valves, piping, and fittings of the

cylinders during rollover accidents.

ï The adequacy of the information in the North American Emergency Response

Guidebook about compressed hydrogen.

Exclusions

The highway in the area of the accident was generally level and straight. The

visibility at the time of the accident was excellent, and the pavement was dry. The

postaccident review of mechanical and maintenance records for the tractor and the

semitrailer indicated that both had been properly maintained. The postaccident inspection

of the pickup truck, the tractor, and the semitrailer was limited by the damage the accident

had inflicted on them. To the extent that inspection was possible, however, no mechanical

problems were found. When the driver of the pickup truck was interviewed, she did not

note any mechanical problems with her vehicle. According to the toxicological tests of

both drivers, neither had used alcohol or illicit drugs. The Safety Board, therefore,

concludes that the following factors can be excluded as causal or contributory to the

accident: highway conditions, weather, the mechanical condition of the vehicles, and

impairment from alcohol and illegal drugs.

The Accident

Witnesses who had followed the pickup truck for about a half mile before the

accident occurred said that the pickup truck driverís driving was erratic and that in the last

moments before the accident, the pickup truck left the roadway briefly and struck a

highway sign before veering back onto the highway and directly into the path of the

tractor-semitrailer. According to those witnesses who saw the tractor-semitrailer moments

before the accident, the truckdriver was operating his vehicle normally and had no

opportunity to avoid the pickup truck. As a result of the collision, he lost control of his

vehicle, which rolled over and began to release hydrogen, which subsequently ignited.

The assertions of the pickup driver that she would not have lost control of her vehicle if

the tractor-trailer had not hit her first are not supported by witness accounts or physical

evidence (damage to pickup truck, tractor, and one-way sign).
Analysis 23 Hazardous Materials Accident Report

Driver Performance

Pickup Driver

Nothing in the driving history of the pickup driver explains her erratic driving just

before the accident. However, her medical conditions or medications may conceivably

have played a role. Her diabetes and high blood pressure seemed to be well managed, and

the medications she took for those conditions are unlikely to impair the user. However, her

anxiety and/or the medication prescribed to treat it could have affected her ability to

control the vehicle. Her anxiety medication has been reported to cause movement

disorders. 

Because the volume of the toxicological specimen of the pickup driverís blood

supplied to the CAMI was limited, the initial screening probably would not have detected

the various drugs she was prescribed. Further, the prescription drugs that she was taking,

metformin, glipizide, and perphenazine, are not detectable by the routine screening

procedures used at the CAMI; and the prescribed doses of verapamil and amitriptyline she

took would be expected to be lower than the laboratoryís cutoff values. 

The Safety Board has previously addressed the issue of medication use by

transportation operators (both commercial and private) and has issued recommendations

to the DOT, the modal administrations, and the U.S. Food and Drug Administration (FDA)

regarding the need for additional guidance for transportation operators about the potential

effects of prescription and over-the-counter medications.24 In addition, the Safety Board

and the FDA co-sponsored a public meeting called ìTransportation Safety and Potentially

Sedating or Impairing Medicationsî on November 14 through 15, 2001.

The pickup driverís driving may have been erratic because she was impaired by a

medical condition, a medication, or fatigue. However, the Safety Board concludes that

because the pickup truck driver was unable to recall information about her activities,

including her use of medications and sleep in the 96 hours before the accident, the Safety

Board cannot determine with any confidence why her driving was erratic or why she lost

control of her vehicle. 

24 On January 13, 2000, the Safety Board issued Safety Recommendations I-00-1 through -5, A-00-4

through -6, H-00-12 through -15, R-00-2 through -8, and M-00-1 through -4. Safety Board staff members

have met with representatives of the DOT modal administrations to discuss implementation of these

recommendations.
Analysis 24 Hazardous Materials Accident Report

Truckdriver

At his last required physical examination, when he was questioned about his

prescription medications and illnesses by the medical examiner, the truckdriver failed to

disclose that he took insulin to control his diabetes or that he was on medication for

anxiety. There is no guidance in the DOT motor carrier regulations about medically

certifying commercial drivers who are being treated for anxiety or chronic pain,25 but

insulin-dependent diabetes is specified as a medical disqualification. The Safety Board

explored the issue of the inappropriate medical certification of commercial drivers in its

report on a May 9, 1999, bus accident in New Orleans, Louisiana.26 In the report, the

Board issued 10 recommendations to the Federal Motor Carrier Safety Administration

(FMCSA) and the American Association of Motor Vehicle Administrators, urging them to

develop comprehensive medical oversight programs for commercial drivers. (See

appendix C.) The Safety Board is currently evaluating the FMCSAís response to Safety

Recommendations H-01-17 through -25. The American Association of Motor Vehicle

Administrators has not yet responded to Safety Recommendation H-01-26. 

The prescription drugs that the truckdriver was taking, pioglitazone, metformin,

alprazolam, and glyburide, are not detectable by the routine screening procedures used at

the CAMI. He was also taking insulin, which is a naturally occurring substance in the

body and is not tested for in routine toxicological testing.

Although the combination of medications that the truckdriver was taking for

diabetes and the medication he was taking for anxiety could have reduced his ability to

operate a commercial motor vehicle safely, witnesses said he appeared to be operating his

vehicle normally before the accident. Also according to witnesses, he could not have

avoided hitting the pickup truck. No physical evidence, such as mechanical difficulties or

road conditions, contradicts the witness accounts. The Safety Board, therefore, concludes

that the truckdriverís operation of the tractor-semitrailer did not cause or contribute to the

accident. 

Performance of Cylinders, Valves, Piping, and Fittings 

Damage to Valves, Piping, and Fittings 

During the accident and rollover, nearly all of the shutoff valves, piping, and

fittings for the 10 cylinders were destroyed by the impact with the roadway and/or terrain.

Eight of the 10 shutoff valves were sheared off, resulting in the release and ignition of the

hydrogen. The master valve was also destroyed by impact damage. The metal cabinet

25 Title 49 CFR 391.41 does, however, note disqualification for ìÖrheumatic, arthritic, orthopedic,

muscular, neuromuscular, or vascular disease which interferes with his/her ability to control and operate a

commercial motor vehicle safelyî and for ìÖmental, nervous, organic, or functional disease or psychiatric

disorder likely to interfere with his/her ability to drive a commercial motor vehicle safely.î

26 National Transportation Safety Board, Motorcoach Run-Off-The-Road Accident, New Orleans,

Louisiana, May 9, 1999, Highway Accident Report NTSB/HAR-01/01 (Washington, D.C: NTSB, 2001).
Analysis 25 Hazardous Materials Accident Report

enclosing the valves, piping, and fittings was also heavily damaged during the accident

and rollover; the cabinet was not sufficiently sturdy to shield and protect the valves and

fittings from impact damage. The extended rear bumper on the semitrailer, which some

manufacturers described as protection for the valves and fittings, was also damaged. More

importantly, on the basis of the damage to the metal cabinet, the impact forces came from

the right side of the semitrailer when it swung around and impacted the roadway and

terrain during its 270-degree rollover. The only protection an extended rear bumper can

provide is from a force applied directly from the rear. 

The configuration of the valves and fittings on the rear of the trailer also increased

their vulnerability to impact damage. The shutoff valves were not positioned at the necks

of the cylinders or recessed in the necks of the cylinders. The piping had limited strength,

given its small diameter and thin walls. The inadequacy of the protection and shielding of

the valves and fittings was critical in allowing the release of the compressed gas.

Therefore, the Safety Board concludes that because the valves, piping, and fittings at the

rear of the semitrailer were not adequately protected and shielded from the impact caused

by the rollover of the semitrailer, 8 of the 10 shutoff valves were sheared off, which

resulted in the release and ignition of the hydrogen

Fracture and Ejection of Cylinder 3

The metallurgical examination of the fracture of cylinder 3 showed that the

fracture was caused by overstress that resulted from forces acting on the cylinder during

the rollover. The fracture was consistent with the impact of the front of the cylinder with

the roadway and/or terrain. Because the outermost cylinders extended beyond the top and

side edges of the bulkheads, the cylinders were exposed and vulnerable to absorbing the

initial impact during a rollover. (See figure 1.) 

The rear neck of the cylinder was also subjected to motions and forces that resulted

in the cylinder rotating loose from the flange, as demonstrated by the off-axis rotational

scoring observed in the interior threads. A similar rotation of cylinder 1 was demonstrated

by the exposed and unpainted threads on its front and rear necks. Therefore, the Safety

Board concludes cylinder 3 absorbed the initial impact with the roadway or terrain,

resulting in the fracture of its front end and the ejection of the cylinder from the

semitrailer.

Standards for Cylinders Horizontally Mounted on Semitrailers

Under the hazardous materials regulations, protection for valves and rupture disks

for DOT specification cylinders horizontally mounted on semitrailers must be designed to

ìwithstand a force equal to twice the weight involved with a safety factor of four, based on

the ultimate strength of the material used.î Although RSPA has not issued a formal written

interpretation of this requirement, RSPA staff has advised the Safety Board that the

requirement applies only to a rear-end strike to the semitrailer. An extended rear bumper
Analysis 26 Hazardous Materials Accident Report

may offer protection from rear strikes, but it affords no protection from the side and top

forces that are typically encountered in a rollover accident.

The regulations do not specify whether the valves, piping, and fittings must be

enclosed and shielded by a protective structure; and the regulations do not explain whether

other options for protection, such as recessed valves and fittings, are acceptable. This lack

of specificity in the regulations led one manufacturer to believe that the cabinet enclosing

the valves, piping, and fittings is designed to protect them from being sheared or broken

off. A second manufacturer believes that an extended rear bumper fulfills the requirements

to protect valves and fittings. Another manufacturer stated that the cabinet must be

constructed to comply with the requirements that apply to portable gas cylinders. There is

no clear and concise requirement in the hazardous materials regulations that addresses the

protection of valves and fittings from forces in a rollover accident. The absence of RSPA

guidance has created differing perceptions within the industry about what is actually

required for protecting valves, piping, and fittings on a semitrailer with horizontally

mounted cylinders. 

Because of the ambiguities of the existing regulations and the various

interpretations among the manufacturers of the vehicles, the Safety Board concludes that

the hazardous materials regulations do not provide sufficient and clear requirements for

protecting cylinders and valves, piping, and fittings of cylinders that are horizontally

mounted on semitrailers. Consequently, the hazardous materials regulations must address

the multidirectional forces that these cylinders, valves, piping, and fittings may experience

in a rollover accident. Therefore, the Safety Board believes that RSPA should modify 49

CFR 173.301 to clearly require that valves, piping, and fittings for cylinders that are

horizontally mounted and used to transport hazardous materials are protected from

multidirectional forces that are likely to occur during accidents, including rollovers. 

Also, cylinder 3 on the accident vehicle was fractured by overstress resulting from

the initial impact of the front of the cylinder on the roadway or terrain during the rollover

of the vehicle, and the cylinder was ejected from the semitrailer. The cylinder was

particularly vulnerable to absorbing the initial impact with the roadway or ground because

its body extended beyond the envelope of the bulkheads. The hazardous materials

regulations are silent regarding the protection and shielding of horizontally mounted

cylinders on semitrailers from initial impact during rollover accidents. According to the

manufacturers of semitrailers with horizontally mounted cylinders, the accident

semitrailer was typical of other semitrailers in service. Consequently, the Safety Board

concludes that because horizontally mounted cylinders on semitrailers typically extend

beyond the envelope of the bulkheads, the cylinders are exposed and vulnerable to initial

impact with the roadway or terrain during rollover accidents and are at increased risk of

damage, failure, and ejection. Therefore, the Safety Board believes that RSPA should

require that cylinders that transport hazardous materials and are horizontally mounted on a

semitrailer be protected from impact with the roadway or terrain to reduce the likelihood

of their being fractured and ejected during a rollover accident. 
Analysis 27 Hazardous Materials Accident Report

Emergency Response 

The Washington County 911 Center was timely in its notifications, and the

emergency responders responded promptly. Even before the Washington County

Emergency Management director had arrived on scene, he wisely requested help in

identifying the hazards associated with compressed hydrogen. 

The director stated that although the accident scene was stable when he arrived, the

initial staging of personnel and emergency equipment was too close to the accident vehicle

and had limited escape routes. The staging area was approximately 40 feet west of the

overturned semitrailer, which was on fire. He considered that the risk of the situation

destabilizing while firefighters broke down their equipment and moved to a safer location

was greater than the risk posed by having the responders continue to spray large amounts

of water on the cylinders to keep them cool. However, it would have been prudent for the

director to relocate the equipment and the personnel not immediately essential to the

cooling operation. 

The firefighters did not move to a safer distance until 3:35 p.m., after a pumper

engine from the Bartlesville fire department, unmanned ground monitors with the Phillips

Petroleum DART, and the chief of the Tulsa hazardous materials team arrived. The chief

and the director concluded that they could maintain the accident sceneís stability while

restaging equipment and personnel. They based their decision on the fact that additional

equipment and the Tulsa hazardous materials team had arrived. 

To address the staging problems at the accident scene, the director and Washington

County have taken positive actions since the accident. One of the actions of Washington

County has been a community-wide drill (fall 2001) that involved a simulated release of

hazardous materials resulting in a simulated fire with multiple simulated injuries and

fatalities. The drill included all fire departments within the county, as well as Phillips

Petroleum. Also, each volunteer fire department within the county is performing drill

scenarios. 

In addition, Washington County established its own hazardous materials response

team and is providing the team members with more advanced training in responding to

hazardous materials accidents.

Emergency Response Guidance

The North American Emergency Response Guidebook is often the first reference

used by the emergency responders who are first to arrive at an accident scene. The first

responders to the Ramona accident used the book and referred to the guide for hydrogen.

However, the guide did not provide complete information about the unique properties of

hydrogen, specifically that hydrogen burns with an invisible, or almost invisible, flame.

The guide also contained generic information about chemical properties, such as vapors

sinking to the ground, which do not apply to hydrogen.
Analysis 28 Hazardous Materials Accident Report

Incomplete or inaccurate information in the guidebook may lead first responders to

take measures that endanger them. Consequently, the Safety Board concludes that

although the incomplete or inaccurate information about hydrogen in the North American

Emergency Response Guidebook was not a factor in this accident, there is the possibility

that the lack of information could increase the risk to emergency response personnel. 

Therefore, the Safety Board believes that RSPA should revise the information

about hydrogen in the North American Emergency Response Guidebook so that it

specifically identifies the unique chemical and flammability properties of hydrogen. 
29 Hazardous Materials Accident Report

Conclusions

Findings

1. The following factors can be excluded as causal or contributory to the accident:

highway conditions, weather, the mechanical condition of the vehicles, and

impairment from alcohol and illegal drugs.

2. Because the pickup truck driver was unable to recall information about her activities,

including her use of medications and sleep in the 96 hours before the accident, the

Safety Board cannot determine with any confidence why her driving was erratic or

why she lost control of her vehicle.

3. The truckdriverís operation of the tractor-semitrailer did not cause or contribute to the

accident.

4. Because the valves, piping, and fittings at the rear of the semitrailer were not

adequately protected and shielded from the impact caused by the rollover of the

semitrailer, 8 of the 10 shutoff valves were sheared off, which resulted in the release

and ignition of the hydrogen.

5. Cylinder 3 absorbed the initial impact with the roadway or terrain, resulting in the

fracture of its front end and the ejection of the cylinder from the semitrailer.

6. The hazardous materials regulations do not provide sufficient and clear requirements

for protecting cylinders and valves, piping, and fittings of cylinders that are

horizontally mounted on semitrailers. 

7. Because horizontally mounted cylinders on semitrailers typically extend beyond the

envelope of the bulkheads, the cylinders are exposed and vulnerable to initial impact

with the roadway or terrain during rollover accidents and are at increased risk of

damage, failure, and ejection.

8. Although the incomplete or inaccurate information about hydrogen in the North

American Emergency Response Guidebook was not a factor in this accident, there is

the possibility that the lack of information could increase the risk to emergency

response personnel.
Conclusions 30 Hazardous Materials Accident Report

Probable Cause

The National Transportation Safety Board determines that the probable cause of

the May 1, 2001, collision and subsequent fire involving a tractor-semitrailer and a pickup

truck in Ramona, Oklahoma, was the failure, for unknown reasons, of the pickup driver to

control her vehicle. Contributing to the severity of the accident were the inadequate

protection and shielding of the cylinders, valves, piping, and fittings and the inadequate

securement of cylinders on the semitrailer.
31 Hazardous Materials Accident Report

Recommendations

As a result of its investigation, the National Transportation Safety Board makes the

following safety recommendations:

To the Research and Special Programs Administration:

Modify 49 Code of Federal Regulations 173.301 to clearly require that

valves, piping, and fittings for cylinders that are horizontally mounted and

used to transport hazardous materials are protected from multidirectional

forces that are likely to occur during accidents, including rollovers.

(H-02-23)

Require that cylinders that transport hazardous materials and are

horizontally mounted on a semitrailer be protected from impact with the

roadway or terrain to reduce the likelihood of their being fractured and

ejected during a rollover accident. (H-02-24)

Revise the information about hydrogen in the North American Emergency

Response Guidebook so that it specifically identifies the unique chemical

and flammability properties of hydrogen. (H-02-25)

BY THE NATIONAL TRANSPORTATION SAFETY BOARD

MARION C. BLAKEY

Chairman

CAROL J. CARMODY

Vice Chairman

JOHN A. HAMMERSCHMIDT

Member 

JOHN J. GOGLIA

Member

GEORGE W. BLACK, JR.

Member

Adopted: September 17, 2002

33 Hazardous Materials Accident Report

Appendix A 

Investigation

The National Response Center notified the Safety Board of the accident by

facsimile in the early morning of May 2, 2001. The Safety Board dispatched a nine-person

team (from Washington, D.C., and field offices) consisting of an investigator-in-charge,

three highway investigators, two hazardous materials investigators, two human

performance investigators, and one survival factors investigator. No Board Member

participated in the on-scene investigation.

No hearings were held on the accident, and no depositions were taken.

Parties to the investigation were the Federal Motor Carrier Safety Administration,

the Oklahoma Highway Patrol, the Tulsa Fire Department, the Washington County

Emergency Management Agency, Airgas Mid-South, Inc., the Oklahoma Department of

Transportation, and CP Industries, Inc. (The Safety Board also provided information about

the investigation on an ongoing basis to the Research and Special Programs

Administration.)
34 Hazardous Materials Accident Report

Appendix B 

Emergency Response Timeline

TIME ACTIONS

May 1

2:15 p.m. Accident occurs; 911 center is notified, Ramona volunteer fire department 

members are dispatched. 

2:16 p.m. Washington County Emergency Management director begins traveling to 

the accident scene. 

Between 2:16 

and 2:21 p.m. 

On-scene witnesses extricate pickup driver from vehicle. 

Airgas Mid-South employee passing the accident notifies the company. 

2:21 p.m. Washington County Emergency Management director asks for assistance 

from the Phillips Petroleum dependable accident response team (DART).

2:22 p.m. Chief of the Ramona volunteer fire department arrives on scene and 

assumes incident command. 

Washington County Emergency Management director notifies Ramona 

fire department responders that the cylinders might be pressurized and 

asks the fire departments from surrounding areas for mutual aid. 

After 2:22 p.m. Firefighters begin to spray water on the burning vegetation and the rear of 

the semitrailer and attempt to extricate the truckdriver from the tractor.

2:25 p.m. Washington County Emergency Operations Center and Washington 

County Emergency Operations Plan are activated.

2:30 p.m. Washington County Emergency Management director arrives and 

assumes incident command from the Ramona fire department chief. 

Oklahoma Highway Patrol officer trained in hazardous materials arrives 

on scene.

2:35 p.m. Washington County Emergency Management director tells the firefighters 

to spray water on the cylinders from a distance. 

Shift superintendent of Phillips Petroleum DART tells the firefighters to 

stay away from the ends of the cylinders. 

2:40 p.m. Firefighters stop trying to extricate the truckdriver because of lack of water 

to continue cooling the cylinders. 

2:55 p.m. More water to cool the cylinders arrives; firefighters deploy more 

handlines to maintain cooling streams on the cylinders. 
Appendix B 35 Hazardous Materials Accident Report

3:00 p.m. Airgas president, vice president, and safety director begin traveling to 

accident scene.

3:11 p.m. Oklahoma Highway Patrol officer trained in hazardous materials requests 

the assistance of the Tulsa fire departmentís hazardous materials 

response team.

3:15 p.m. Firefighters extricate the truckdriver.

3:30 p.m. Tulsa fire departmentís hazardous materials team begins to arrive. 

3:35 p.m. Chief of the Tulsa hazardous materials team assumes incident command 

and directs the firefighters to move away from the fire. He moves the fire 

suppression personnel across the highway and sets up system of water 

shuttles and unmanned monitors. 

Tulsa hazardous materials team surveys the condition of the cylindersí 

valves and monitors the cylindersí temperature.

4:00 p.m. Airgas safety director offers the assistance of the Airgas AERO team to 

the chief of the Tulsa hazardous materials team. 

5:15 p.m. AERO team arrives to assist the firefighters with cooling and monitoring 

operations.

6:00 p.m. Chief of the Tulsa hazardous materials team and the Washington County 

Emergency Management director consider the accident scene stabilized 

and discuss releasing the Tulsa fire department units.

6:30-6:40 p.m. Tulsa fire department responders demobilize and leave the scene.

6:40 p.m. Washington County Emergency Management director resumes incident 

command and directs Airgas to monitor cylinder temperature and the 

firefighters to continue cooling operations.

May 2 

12:20 a.m. Airgas personnel advise that all cylinders are vented and fire is out.

12:55 a.m. Washington County Emergency Management director leaves the scene 

and the Oklahoma Highway Patrol assumes incident command.

1:03 a.m. Last fire and rescue units leave the scene.

6:00 a.m. Highway reopens.
36 Hazardous Materials Accident Report

Appendix C 

Safety Recommendations Issued as a Result of Highway 

Accident Report NTSB/HAR-01/01

To the Federal Motor Carrier Safety Administration:

H-01-17 through -25

Develop a comprehensive medical oversight program for interstate commercial

drivers that contains the following program elements:

H-01-17

Individuals performing medical examinations for drivers are qualified to do so

and are educated about occupational issues for drivers. 

H-01-18

A tracking mechanism is established that ensures that every prior application by

an individual for medical certification is recorded and reviewed. 

H-01-19

Medical certification regulations are updated periodically to permit trained

examiners to clearly determine whether drivers with common medical conditions

should be issued a medical certificate. 

H-01-20

Individuals performing examinations have specific guidance and a readily

identifiable source of information for questions on such examinations. 

H-01-21

The review process prevents, or identifies and corrects, the inappropriate issuance

of medical certification. 

H-01-22

Enforcement authorities can identify invalid medical certification during safety

inspections and routine stops. 

H-01-23

Enforcement authorities can prevent an uncertified driver from driving until an

appropriate medical examination takes place. 
Appendix C 37 Hazardous Materials Accident Report

H-01-24

Mechanisms for reporting medical conditions to the medical certification and

reviewing authority and for evaluating these conditions between medical

certification exams are in place; individuals, health care providers, and employers

are aware of these mechanisms. 

H-01-25

Develop a system that records all positive drug and alcohol test results and refusal

determinations that are conducted under the U.S. Department of Transportation

testing requirements, require prospective employers to query the system before

making a hiring decision, and require certifying authorities to query the system

before making a certification decision. 

To the American Association of Motor Vehicle Administrators:

H-01-26

Urge your member States to develop a comprehensive medical oversight program

for intrastate commercial drivers that contains the following program elements:

ï Individuals performing medical examinations for drivers are qualified to do so

and are educated about occupational issues for drivers. 

ï A tracking mechanism is established that ensures that every prior application

by an individual for medical certification is recorded and reviewed.

ï Medical certification regulations are updated periodically to permit trained

examiners to clearly determine whether drivers with common medical

conditions should be issued a medical certificate.

ï Individuals performing examinations have specific guidance and a readily

identifiable source of information for questions on such examinations.

ï The review process prevents, or identifies and corrects, the inappropriate

issuance of medical certification.

ï Enforcement authorities can identify invalid medical certification during safety

inspections and routine stops.

ï Enforcement authorities can prevent an uncertified driver from driving until an

appropriate medical examination takes place.

ï Mechanisms for reporting medical conditions to the medical certification and

reviewing authority and for evaluating these conditions between medical

certification exams are in place; individuals, health care providers, and

employers are aware of these mechanisms.