highway

Motorcoach Fire on Interstate 45

During Hurricane Rita Evacuation

Near Wilmer, Texas

September 23, 2005

ACCIDENT REPORT

NTSB/HAR-07/01

Nati PB2007-916202 onal

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

PB2007-916202 National Transportation Safety Board

Notation 7774C 490 L’Enfant Plaza, S.W.

Adopted February 21, 2007 Washington, D.C. 20594
National Transportation Safety Board. 2007. Motorcoach Fire on Interstate 45 During Hurricane Rita 

Evacuation Near Wilmer, Texas, September 23, 2005. Highway Accident Report NTSB/HAR-07/01.

Washington, DC.

Abstract: 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.

Major safety issues identified in this investigation include vehicle fire reporting and inconsistent data within 

Federal accident databases, the ineffective compliance review program of the Federal Motor Carrier Safety 

Administration (FMCSA), 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 FMCSA, 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, MCI 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.

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

Records Management Division, CIO-40

490 L’Enfant 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 PB2007-916202 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 Highway Accident Report

Contents

Acronyms and Abbreviations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . v

Executive Summary . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .vii

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

Preaccident Events . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1

Accident Narrative . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1

Emergency Response . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8

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

Motorcoach Evacuation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9

Damage . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11

Driver Information . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12

Certification and Experience . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12

Duty Status . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14

Vehicle Information . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15

Tag Axle . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 16

Vehicle Ownership . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 18

Vehicle Fires . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 22

Motorcoach Fire Data Sources . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 22

Volpe National Transportation Systems Center . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 23

Tire Fires and Fire Suppression Systems . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 24

Highway Information . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 25

General . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 25

Traffic . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 26

Operations Information . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 26

Global Limo Inc. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 26

Federal Motor Carrier Safety Administration . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 29

Nursing Home Information . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 33

Bus Brokers . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 34

Oxygen Cylinders . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 35

Meteorological Information . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 37

Toxicological Information . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 38

Other Information . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 38

Commercial Vehicle Inspections . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 38

Motorcoach Tire Fire Testing . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 39

Federal Railroad Administration Research . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 40

Motorcoach Fires and Research Studies in Germany and Finland . . . . . . . . . . . . . . . . 41

DOT Evacuation Research Studies . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 42

Federal Motor Vehicle Safety Standards . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 44

Emergency Evacuation of Persons With Special Needs . . . . . . . . . . . . . . . . . . . . . . . . . 44

Federal Evaluation of Catastrophic Hurricane Evacuation Plan . . . . . . . . . . . . . . . . . . 47

GAO Report on Disaster Preparedness . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 48

Lessons Learned From Federal Response to Hurricane Katrina . . . . . . . . . . . . . . . . . . 49
Contents iv Highway Accident Report

Analysis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 50

Exclusions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 50

Accident Discussion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 52

Heat Source and Fire Ignition . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 53

Motorcoach and Bus Fire Data . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 55

Fire Propagation Into Fuel Sources . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 56

Fire Propagation Into Passenger Compartment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 57

Tire Fires and Fire Suppression Systems . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 58

Vehicle . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 59

Bus Brokers . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 62

Federal Motor Carrier Safety Administration . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 63

Survival . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 69

Motorcoach Emergency Egress . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 69

Evacuation Studies . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 70

Emergency Exit Design . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 72

Oxygen Cylinders . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 74

Emergency Evacuation of Persons With Special Needs . . . . . . . . . . . . . . . . . . . . . . . . . . . . 76

Conclusions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 80

Findings . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 80

Probable Cause . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 82

Recommendations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 83

New Recommendations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 83

Reiterated Recommendations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 86

Appendixes 

A: Investigation and Public Hearing . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 111

B: Global Limo Inc. Federal Motor Carrier Safety 

Administration Compliance Reviews . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 112

C: Federal Motor Carrier Safety Administration Safety Program . . . . . . . . . . 117

D: Excerpts From Federal Motor Carrier Safety Regulations . . . . . . . . . . . . . 119

E: Excerpts From Federal Railroad Administration Testimony . . . . . . . . . . . . 128

F: Emergency Evacuation of Special Needs Populations: Major 

Federal Studies Since Hurricanes Katrina and Rita . . . . . . . . . . . . . . . . . . . . . 131
v Highway Accident Report

Acronyms and Abbreviations

AASHTO American Association of State Highway and Transportation Officials 

ABS antilock brake system

ADA Americans With Disabilities Act

ANSI American National Standards Institute 

ASTM American Society for Testing and Materials

CAPRI Compliance Analysis and Performance Review Information System

CDL commercial driver’s license

CFR Code of Federal Regulations

CGA Compressed Gas Association

CMS Centers for Medicare and Medicaid Services (HHS)

CSA Comprehensive Safety Analysis 2010 Initiative

CUSA Coach USA, LLC

CVSA Commercial Vehicle Safety Alliance

DDEC Detroit Diesel Electronic Controls

DHS U.S. Department of Homeland Security

DOT U.S. Department of Transportation

DVIR driver vehicle inspection report

ECM electronic control module

EMS emergency medical services

ESF emergency support function (NRP)

F Fahrenheit

FAA Federal Aviation Administration

FARS Fatality Analysis Reporting System (NHTSA)

FEMA Federal Emergency Management Agency

FHWA Federal Highway Administration

FM Farm-to-Market

FMCSA Federal Motor Carrier Safety Administration

FMCSRs Federal Motor Carrier Safety Regulations

FMVSS Federal Motor Vehicle Safety Standard

FOP Fraternal Order of Police

FR Federal Register

FRA Federal Railroad Administration

GAO U.S. Government Accountability Office
Acronyms and Abbreviations vi Highway Accident Report

GES General Estimates System (NHTSA)

HHS U.S. Department of Health and Human Services

HM hazardous materials

HMR Hazardous Materials Regulations

HVAC heating, ventilating, and air conditioning

I-45 Interstate 45

IACP International Association of Chiefs of Police

IAFC International Association of Fire Chiefs

IAFF International Association of Fire Fighters

ISS inspection selection system

MCI Motor Coach Industries, Inc.

MCMIS Motor Carrier Management Information System (FMCSA)

MCT MCT Charter Tours

MP milepost

NASEMSO National Association of State EMS Officials

NDMS National Disaster Medical System 

NFIRS National Fire Incident Reporting System (NFPA)

NFPA National Fire Protection Association

NHTSA National Highway Traffic Safety Administration

NIST National Institute of Standards and Technology

NPRM Notice of Proposed Rulemaking

NRP National Response Plan

NSA National Sheriffs’ Association

NVFC National Volunteer Fire Council

OOS out-of-service

PHMSA Pipeline and Hazardous Materials Safety Administration

psig pounds per square inch gage

PVC polyvinyl chloride

SafeStat Safety Status Measurement System (FMCSA)

SAFETEA-LU Safe, Accountable, Flexible, Efficient Transportation Equity Act: A 

Legacy for Users

SEA safety evaluation area (FMCSA)

TBPC Texas Building and Procurement Commission

TxDOT Texas Department of Transportation

TxDPS Texas Department of Public Safety

UL Underwriters Laboratories Inc.

VIN vehicle identification number
vii Highway Accident Report

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 

posttrip 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.
viii Highway Accident Report

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.

Executive Summary
1 Highway Accident Report

Factual Information

Preaccident Events

On September 20, 2005, the Governor of Texas issued a proclamation of an 

imminent hurricane threat and urged residents living in coastal areas to evacuate prior to 

landfall by Hurricane Rita.1 On September 21, the mayor of Galveston, Texas, issued a 

mandatory evacuation order for the coastal city and surrounding areas. Also on that day, 

staff at the Brighton Gardens of Bellaire (Brighton Gardens) senior assisted living center, 

located in a Houston suburb approximately 50 miles inland from Galveston (and within 

the projected path of the hurricane), began the process of evacuating residents to two 

facilities in Dallas and Arlington, Texas.

Brighton Gardens was operated by Sunrise Senior Living Services, Inc. (Sunrise), 

headquartered in McLean, Virginia. Sunrise contacted the BusBank2 and negotiated a 

contract to transport residents from Bellaire to Dallas, an expected 4-hour trip, beginning 

about 9:00 a.m. on September 22.3 The BusBank contracted with Global Limo Inc. 

(Global) to provide two motorcoaches4 for evacuation of the Brighton Gardens residents 

and nursing staff. On September 22, the President of the United States issued a 

Declaration of Emergency for the State of Texas because Hurricane Rita was expected to 

make landfall near Galveston on September 24.

Accident Narrative

On September 22, 2005, the accident motorcoach driver departed Pharr, Texas, 

about 5:00 a.m., drove approximately 360 miles, and arrived at Brighton Gardens in 

Bellaire about 11:00 a.m. While Brighton Gardens staff prepared residents for the 

evacuation, the driver napped in the vehicle for about 2 hours. About 1:30 p.m., 37 

assisted living facility residents, 6 nursing staff, and 1 staff parent were loaded into the 

motorcoach. Firefighters assisted in boarding passengers with special needs, a process that 

1 Hurricane Rita was one of the strongest storms on record for the Atlantic Basin. By the afternoon of 

September 21, 2005, Rita had reached category 5 strength on the Saffir–Simpson scale, with winds of 165 mph. 

The storm brought hurricane-strength winds more than 150 miles inland and caused significant damage along 

the coast. Rita made landfall along the Texas–Louisiana border early on September 24 as a category 3 storm 

with sustained winds of 120 mph. See <www.ncdc.noaa.gov/oa/climate/research/2005/rita.html#met>,

November 8, 2006.

2 According to the BusBank website, the company is a “group and event transportation specialist.” See 

<www.busbank.com/aboutus.aspx>, September 20, 2006.

3 Unless otherwise indicated, all times in this report are central daylight time.

4 The contract requested two motorcoaches. The second motorcoach, transporting 16 ambulatory 

passengers, departed Brighton Gardens about 6:00 p.m. on September 22, 2005. It arrived at its destination 

about 9:30 a.m. on the following day.
Factual Information 2 Highway Accident Report

took 1.5 to 2 hours. In addition, Brighton Gardens staff loaded 22 wheelchairs, 5 walkers, 

and 18 medical oxygen cylinders5 into the luggage compartments.

According to the 37-year-old motorcoach driver, he departed Brighton Gardens 

between 3:00 and 3:30 p.m. When he attempted to head north on Interstate 45 (I-45), he 

found it to be closed. Alternatively, he traveled east on Interstate 610 to U.S. Route 59 

north, then headed west on State Highway 105. About 4:00 p.m., the nursing staff asked 

the driver to pull over so they could retrieve two full oxygen cylinders for the passengers 

who needed oxygen. The driver stated that the vehicle entered I-45 about 7:00 p.m. and 

exited at Huntsville, Texas, to refuel. Ten minutes after returning to the interstate, the 

driver was asked by the nursing staff to pull over so they could retrieve an additional four 

full oxygen cylinders; the driver then continued north on I-45. (See figure 1.)

On September 23, the accident motorcoach was still traveling north on I-45 about 

3:15 a.m. when, just prior to the Farm-to-Market (FM) 1126 overpass, near exit 239, the 

right-side tag axle wheel locked and began to produce 1,500 feet of dragging tire marks on 

the roadway. The driver said that he then heard the right-rear tire blow out, and he pulled 

off the roadway near the FM 1126 entrance ramp, which was about 400 feet from the 

location of the tire blowout. The driver exited the motorcoach and checked the tire. He 

saw that the right tag axle tire was flat, returned to the vehicle, and continued driving north 

to try and find a suitable location to pull off for a tire change. The driver operated the 

vehicle a total of 6,800 feet from the initial tire lockup to the location where he pulled over 

on the right shoulder, partially blocking the right lane and impeding traffic.

The Navarro County Sheriff’s Office received a cellular telephone call at 3:22 a.m. 

from a nurse passenger, who reported the flat tire and requested assistance. A Rice Police 

Department officer was dispatched; a tow truck mechanic was delayed 1 hour because of 

heavy evacuation-related traffic. By 4:30 a.m., the towing service arrived on scene. The 

mechanic removed the flat tire and replaced it with the spare, estimating that the entire tire 

change took less than 5 minutes; the motorcoach driver had already placed the spare tire 

next to the flat tire, and he subsequently placed the flat tire in the spare compartment. Once 

the tire was changed, the Rice police officer advised the driver and the mechanic to drive 

their vehicles to the next exit to complete payment. About 4:40 a.m., just off exit 242, the 

nursing supervisor paid the service repair bill. According to the mechanic, he was unaware 

of the long tire marks leading to the location where he replaced the flat tire. He also 

reported that he did not see anything unusual about the tire and wheel and that he and the 

driver did not have any discussion regarding the vehicle while he was changing the tire.

The motorcoach driver reentered I-45 about 5:00 a.m. and continued north. Less 

than 1 hour later, about 2,100 feet south of the Mars Road exit, a motorist also traveling 

north on I-45 noticed that the right-rear wheel of the motorcoach was glowing red hot, 

with sparks emanating from the wheel. The motorcoach was traveling in the left lane. The 

motorist maneuvered his vehicle in front of the motorcoach and slowed down until the 

motorcoach came to a stop. He exited his vehicle and approached the driver’s window to 

tell him that the right-rear wheel was glowing orange-red. The motorist later told Safety 

5 Because two residents required medical oxygen, two of the cylinders were loaded into the seating area.
Figure 1. Regional map and accident motorcoach evacuation route.

N

Not to scale

Wilmer

Rice (tire change)

Bellaire (starting point)

Conroe

45

59

610

Houston

Dallas

MP 269.5 (accident location)

Dallas

Houston

45

TEXAS

Factual Information 3 Highway Accident Report
Factual Information 4 Highway Accident Report

Board investigators that he was unsure whether the motorcoach driver understood him 

because the driver never responded verbally. The motorist then returned to his vehicle and 

drove away. The supervising nurse reported hearing the motorist approach the motorcoach 

driver and report a problem with the right-rear wheel. The driver began to move the 

motorcoach across the crowded lanes of travel and pulled off onto the right shoulder north 

of the Mars Road exit, at milepost (MP) 269.5. (See figure 2.)

Figure 2. Accident scene diagram.

N

32-inch concrete barrier 

 Gouge marks

 End of tire marks

 Motorcoach

 Burned area

 Beginning 

 of tire marks

 Motorcoach

 stopped by motorist

 Mars Road

 Exit 269

MP 269.5 

200' 400'

100' 300' 500'

Scale

0'
Factual Information 5 Highway Accident Report

The driver, nurse supervisor, and another nurse exited the motorcoach and observed 

the right-rear wheel well on fire. As the driver began trying to extinguish the flames with 

his shirt and by throwing dirt and grass, the nurses immediately went back into the vehicle 

and urged the passengers to quickly exit. As the nursing staff was evacuating the 

nonambulatory passengers, the driver had reentered the motorcoach and attempted to 

unlatch the fire extinguisher from its bracket under the right (passenger)-side second row 

seat. He was unable to unlatch it and reported opening a roof hatch vent instead; he tried 

opening a few windows on the driver’s side but said that they would not stay open.

About 6:07 a.m., Dallas County and the city of Wilmer dispatchers received a 911 

call reporting the fire. Two Wilmer Police Department officers had arrived on scene by 

6:12 a.m., and one officer, along with motorists who had stopped to help, entered the 

motorcoach to help the nonambulatory passengers evacuate. Witnesses interviewed by the 

Safety Board reported trying unsuccessfully to pry open the motorcoach windows from 

outside; two passersby broke the glass in two windows, but they were unable to rescue 

anyone through the broken windows. (See figure 3.)

Figure 3. Damaged motorcoach on I-45 following fire.

At the time of the accident, local media were in the vicinity filming the heavy 

interstate traffic. In addition to a photograph provided by a witness (see figure 4), KTVT 

television, a CBS affiliate in Dallas–Fort Worth, provided the Safety Board with a video of 

the motorcoach fire, with elapsed time recorded in the upper left corner of the images. The 

Safety Board constructed the following sequence of events from the images:

• About 6:08 a.m., approximately 3 minutes after the motorcoach pulled onto the 

right shoulder of I-45 (the 911 call was placed at 6:07 a.m.), fire is visible from 

the rear on the right side of the vehicle. (See figure 5.)
Factual Information 6 Highway Accident Report

• Less than 15 seconds later, the entire rear of the vehicle is engulfed in flames.

• An intense burst of fire is visible about 3 minutes later. (See figure 6.)

• By 6:15 a.m., 6.5 minutes into the video, the motorcoach is almost completely 

engulfed in flames. (See figure 7.)

Figure 4. Motorcoach tire on fire, witness photo from I-45 frontage road. 

(Courtesy of Dallas County Sheriff’s Office)

Figure 5. Video image 1 of accident motorcoach. (Courtesy of KTVT, Dallas–Fort Worth)
Figure 6. Video image 2 of accident motorcoach. (Courtesy of KTVT, Dallas–Fort Worth)

Figure 7. Video image 3 of accident motorcoach. (Courtesy of KTVT, Dallas–Fort Worth)

Factual Information 7 Highway Accident Report
Factual Information 8 Highway Accident Report

Emergency Response

The second Wilmer police officer who had arrived on scene about 6:12 a.m. began 

to direct traffic away from the burning vehicle. By 6:15 a.m., two deputies from the Dallas 

County Sheriff’s Office arrived on scene; fire within the motorcoach prevented them from 

entering the vehicle to assist in the passenger evacuation. The Wilmer and Hutchins Fire 

Departments arrived on scene from opposite directions by 6:24 a.m. and reported that the 

motorcoach was completely engulfed in flames. Thirteen local emergency service 

agencies responded to the fire, along with nine ambulances from four agencies and a 

private ambulance service.

A grass fire had occurred approximately 3.2 miles south (near exit 266) of the site 

of the motorcoach fire, in the median between the northbound and southbound lanes. 

This fire was reported to the Ferris Volunteer Fire Department at 6:04 a.m., approximately 

3 minutes prior to the 911 call reporting the motorcoach fire. The Safety Board examined 

the location of the grass fire and recovered two metal objects similar in appearance to 

objects removed from the accident motorcoach tag axle wheel and hub assembly during a 

Safety Board postaccident inspection.6

The Safety Board interviewed several of the first responders and dispatchers, who 

reported some delays in emergency response to the motorcoach fire. Interviewees stated: 

the initial 911 calls reported the vehicle fire location north of the actual accident site; 

hurricane evacuation traffic was extremely congested; the Wilmer Fire Department was 

staffed with only two firefighter/emergency medical technician personnel at night; and the 

Wilmer dispatch office had only one dispatcher on duty, who handled all incoming and 

outgoing emergency calls, including the dispatching of personnel and equipment. 

Subsequently, on March 15, 2006, the city of Wilmer dispatch office installed two fourchannel CD loggers with digital voice recorders to handle 911 calls.

Injuries

Twenty-three passengers died in the motorcoach fire. According to medical examiner 

autopsy reports from the Southwestern Institute of Forensic Sciences in Dallas, Texas, the 

causes of death were smoke inhalation and thermal injuries. Six nursing staff personnel, 1 

parent of a nursing staff member, and 14 passengers escaped. Of these survivors, 2 passengers 

were seriously7 injured, and 19, along with the driver, sustained minor injuries. The driver and 

14 passengers were transported to two local hospitals for treatment of smoke inhalation, an 

arm fracture, minor lacerations, contusions, and burns. (See table 1.)

6 These objects were examined by the Safety Board metallurgy laboratory and determined to be rollers 

from the accident motorcoach right-side tag axle outer wheel bearing.

7 One passenger sustained a right arm fracture, and one passenger was hospitalized with a seconddegree facial burn and smoke inhalation injury.
Factual Information 9 Highway Accident Report

Table 1. Injuries.

Motorcoach Evacuation

Most of the 37 patient-passengers had moderate-to-severe mobility or cognitive

impairments8 and were not able to evacuate during the fire without assistance. Twentytwo passengers had occupied nursing facility beds at Brighton Gardens, at least 13 of

who did not walk at all, and 5 required extensive assistance to walk; 7 of these

passengers had “moderately impaired” decision-making skills.9 Of the 15 passengers

who had not occupied nursing facility beds, 9 required a walker or wheelchair for

ambulation, and 4 were diagnosed or described as having dementia, forgetfulness, or

hysteria.

According to the nursing staff on board the motorcoach, many of the passengers

refused to evacuate, did not understand the urgency of escaping the approaching fire, or

actively fought efforts to physically move them from the motorcoach. Of the 14

passengers who evacuated, many had to be pulled, pushed, or dragged out the front

loading door by nurses or rescuers.

The 23 passengers who died in the fire ranged from 68 to 100 years old. Eighteen

individuals were found still seated, and 5 were found in the center aisle. One of these

passengers had reportedly been seated in row 10 and was found near the front of the

motorcoach in the aisle adjacent to row 1. (See figure 8.10)

InjuryA

Motorcoach 

driver

Motorcoach 

passengers

Staff

and parent Total

Fatal 0 23 0 23

Serious 0 2 0 2

Minor 1 12 7 20

None 0 0 0 0

Total 1 37 7 45

A

Title 49 Code of Federal Regulations (CFR) 830.2 defines fatal injury as any injury that results in

death within 30 days of the accident. It defines serious injury as an injury that requires

hospitalization for more than 48 hours, commencing within 7 days of the date of injury; results in a

fracture of any bone (except simple fractures of fingers, toes, or nose); causes severe

hemorrhages, or nerve, muscle, or tendon damage; involves any internal organ; or involves secondor third-degree burns, or any burn affecting more than 5 percent of the body surface.

8 Based on State and federally required Minimum Data Set reports and State-required Individual

Service Plans.

9 These patients required reminders, cues, and supervision in decision-making.

10 The seating chart shown in figure 8 is based on interviews with nursing staff and patients; it may not

depict the exact seating locations immediately prior to the fire.
Figure 8. Passenger seating chart and postfire injury information.

M - 78 : Minor

M - 76 : Minor

 F - 81 : Minor

M - 81 : Serious

 F - 94 : Fatal

*F - 59 : Minor

**F - 79 : Minor

*F - 50 : Minor

F - 87 : Fatal

M - 78 : Minor

*F - 57 : Minor 

F - 84 : Minor

F - 87 : Minor

F - 93 : Fatal 

F - 100 : Fatal

F - 85 : Fatal

F - 92 : Fatal

*F - 42 : Minor

F - 84 : Minor

 M - 37 : Minor

F - 77 : Fatal 

F - 91 : Fatal

F - 80 : Fatal

*F - 51 : Minor 

*F - 55 : Minor

F - 84 : Fatal

 F - 79 : Fatal

M - 86 : Fatal

F - 89 : Fatal

M - 89 : Fatal

SAMPLE

F = FEMALE M = MALE # = AGE

+International Civil Aviation Organization

+INJURY LEVEL

AGE

GENDER

F - 14 : Minor

Source: NTSB

F - 79 : Fatal

F - 91 : Fatal

F - 92 : Fatal

F - 78 : Minor

M - 93 : Minor

M - 90 : Fatal 

M - 79 : Fatal 

M - 74 : Fatal 

M - 78 : Fatal

M - 68 : Minor 

F - 68 : Fatal

F - 84 : Serious

M - 92 : Fatal

F - 87 : Minor

 F - 99 : Minor

3

1

2

4

5

6

7

8

9

10

11

12

13

14

* Indicates Nursing Staff

** Indicates Nursing Staff Parent

Factual Information 10 Highway Accident Report
Factual Information 11 Highway Accident Report

The Safety Board interviewed the nursing staff regarding evacuation of the 

motorcoach. The nursing supervisor reported that when she informed the staff they needed 

to get the passengers off the motorcoach, she and other nursing team members and even 

bystanders began assisting passengers. She did not recall anyone opening windows during 

the evacuation, and other nursing staff reported not being able to open the side windows 

because they could not see the latches. The nursing staff reported that the flames began 

entering the motorcoach through the last window on the right side and spread to the 

newspapers that had been placed on the windows to help shade the interior during the day. 

Several of the passengers who were able to walk and understood the need to evacuate 

waited at the front loading door for assistance down the steps.

The Safety Board also interviewed emergency responders and passersby who 

stopped to aid in the rescue of passengers. The interviewees explained that almost as soon 

as they observed the fire in the wheel well of the motorcoach and pulled over to assist, 

thick black smoke began to accumulate inside the vehicle and could be seen coming out 

the front door.

The Wilmer Police Department received notification of the fire at 6:08 a.m. An 

officer arrived on scene within 1–2 minutes and observed flames already past the wheel 

well area and moving up the side of the motorcoach, smoke pouring out the front door, and 

the rear windows covered by flames and smoke. He assisted in evacuating one person 

seated in the first row and then assisted in evacuating several more, by which time smoke 

was present from the ceiling to the floor level, and fire debris was falling from the ceiling.

A passerby explained that when he and a coworker stopped to help, the smoke 

made him sick after one rescue attempt inside the motorcoach, and he instead tried to 

reach inside through an open window to pull out a passenger. His coworker stated that he 

was able to rescue two passengers but then had to stop because the smoke was too thick to 

reenter the motorcoach, and he instead tried to open a window. Another passerby stated 

that he had made up to four trips into the front of the motorcoach to assist passengers in 

evacuating, but then it became too smoky to proceed beyond the first several rows of 

seats, and he had to crawl back to the front door to escape. A fourth passerby stated that he 

pulled over to assist at the same time as the police officer, but he moved only about 10 feet 

into the motorcoach before he had to retreat because of the smoke. The interviewees 

reported hearing several “explosions” from the rear of the motorcoach and then ceased 

rescue attempts.

Damage

The body panels below the side windows and above and below the floor line of the 

accident motorcoach were constructed of fiberglass-reinforced plastic,11 except for the 

painted aluminum baggage door panels. The fire destroyed the majority of the fiberglass 

11 Motor Coach Industries, Inc., MCI 102E Series Maintenance Manual (Schaumburg, IL: MCI, 1997) 

3A-1.
Factual Information 12 Highway Accident Report

body; the chassis steel frame, rear engine compartment, and aluminum cargo compartment 

doors were intact. Only the tubular frame structure remained from the base of the windows 

upward toward the roof.

Two fiberglass-covered access panels were located under the motorcoach in the 

wheel well area. The rearmost cover panel was consumed by fire, and the forward cover 

was charred. Fire consumed the flexible thermoplastic fuel line tubing from the engine 

compartment to less than 1 foot from the fuel tank, in addition to most of the combustible 

materials12 in the wheel well area.

The windshield and all side window glass were missing. According to witness 

statements, the windshield right pane and several windows along both sides of the 

motorcoach were broken out by some of the bystanders who assisted in the evacuation 

effort. The interior of the motorcoach was destroyed by fire. The fire consumed all 

nonsteel seating materials and combustible component sections, in addition to the 

plywood and vinyl center aisle flooring in the rear of the compartment above the service 

tunnel. The heating, ventilating, and air conditioning (HVAC) system was largely 

destroyed by fire. The recirculation duct in the right-rear wheel area was missing, and 

sections of the aluminum return ducts were destroyed and missing; adjoining parts showed 

signs of severe heat exposure. The missing sections had been located above the wheel well 

areas on both sides of the coach.

Driver Information

Certification and Experience

The 37-year-old motorcoach driver held a country of Mexico licencia Federal de 

Conductor (commercial driver’s license [CDL]) permitting him to transport passengers in 

Mexico.13 The driver’s license was issued on September 2, 1998, with an expiration date 

of September 2, 2006.14

The driver had first received a Mexican CDL on September 2, 1988. During an 

interview with the Safety Board, the driver said, through an interpreter, that he began 

working for his family’s motorcoach service in Mexico as a mechanic helper. He eventually 

began driving motorcoaches on trips within Mexico and between Mexico and the United 

States. The driver had begun his recent employment with Global in February 2005.15

12 These items included six tires, six air bags used for load leveling, mud flaps, six bump stops, and 

bushings on the stabilizer bar and torque rods.

13 This endorsement is similar to the U.S. CDL class “B” passenger endorsement.

14 The Mexican CDL is issued for 10 years; the driver is required to renew the license and provide a 

valid medical certificate every 2 years during that period. The accident driver’s license was issued in 1998; it 

showed an embossed “04,” indicating that the license required the 2-year renewal by September 2, 2006. 

The plastic license packet is embossed over the appropriate expiration year to certify that the license is valid.

15 Previous to his current employment, the driver had worked for Global temporarily from February 

2002–August 2003.
Factual Information 13 Highway Accident Report

The back of the Mexican license contains an area for the driver to respond with a 

“yes” or “no” for diabetes, hypertension, and corrective lenses. The driver had indicated 

negative responses on his license; when interviewed by the Safety Board,16 he stated that 

he did have type 2 diabetes.17 The driver reported that he had been under the care of a 

doctor in Monterrey, Nuevo Leon, and that his wife picked up his oral diabetes 

prescription in Mexico. During a postaccident examination of the motorcoach contents, an 

opened container of metformin tablets was found in the driver’s belongings.18

On March 7, 2005, Global had referred the driver to a physician in the United 

States for a U.S. Department of Transportation (DOT) medical examination. The 

examining physician refused to issue a U.S. medical certificate because the driver had 

been diagnosed with type 2 diabetes in 1998. The physician wrote on the medical 

examination form that the driver “needs to show proof of diabetic control” before he could 

be certified fit for duty. He then issued the driver a prescription for diabetes medical 

testing. The accident driver did not report for the medical tests.

According to the Dallas County Sheriff’s Office, in an accident supplemental 

report dated October 5, 2005, the motorcoach driver did not possess a Texas driver’s 

license. The driver had been living in Pharr, Texas, since February 2005, 7 months prior to 

the date of the accident. According to Texas Transportation Code 521.029, a new resident 

moving into Texas, who has a valid CDL from his home State or country, has 30 days after 

entry to secure a Texas CDL. Applicants must visit a local Texas Driver License Office 

and present proof of identity, social security number, and vehicle registration and liability 

insurance, if applicable; submit the required forms and fee; pass the vision exam; and 

surrender the valid out-of-State license (CDL).19

According to the Federal Motor Carrier Safety Administration (FMCSA), CDLs 

issued by the United Mexican States meet established U.S. standards, and all Mexican 

drivers operating in the United States must have an appropriate license from their 

country.20 On September 23 and 25, 2005, and April 5, 2006, the Safety Board conducted 

three interviews with the accident motorcoach driver using Spanish–English interpreters 

provided by the Texas Department of Public Safety (TxDPS), because the driver was 

unable to converse in English.21

16 This interview took place on September 25, 2005, in Dallas, Texas. The Safety Board did not obtain 

copies of the driver’s medical records from Mexico to verify his statements regarding medical care.

17 According to 49 CFR 391.41(b)(3), a person is physically qualified to drive a commercial motor 

vehicle if he or she has no established medical history or clinical diagnosis of diabetes mellitus that requires 

insulin.

18 Metformin, an oral antidiabetic medication, is sold in Mexico as metformina.

19 See <www.txdps.state.tx.us/administration/driver_licensing_control/faq/answers_dl_id.htm#q34>, 

December 11, 2006.

20 See <www.fmcsa.dot.gov/rules-regulations/administration/fmcsr/fmcsrruletext.asp?rule_toc=752&

section=383.23§ion_toc=1315&guidence=Y>, January 16, 2007.

21 A nursing staff member spoke limited Spanish and was able to communicate with the driver.
Factual Information 14 Highway Accident Report

Prior to the accident, on February 12, 2005, the driver had been pulled over for a 

roadside inspection while driving a commercial vehicle (motorcoach) on Interstate 10 in 

Harris County, Texas. The inspector noted (as a discrepancy) on the roadside inspection 

report that the driver was non-English-speaking.22 Title 49 CFR 391.11(b) defines the 

qualifications for commercial vehicle drivers, specifying the requirement that the driver 

“can read and speak the English language sufficiently to converse with the general public, 

to understand highway traffic signs and signals in the English language, to respond to 

official inquires, and to make entries on reports and records.”

Duty Status

The following information was provided to the Safety Board by the motorcoach 

driver during three postaccident interviews. The driver awoke about 8:00 a.m. on 

September 21 and reported for work at 9:30 a.m. He changed the air conditioning filters 

on the accident motorcoach and was informed by his employer that he would be on call for 

a possible Federal Emergency Management Agency (FEMA) transportation charter. The 

driver said that he went shopping with his wife at 10:30 a.m. and returned home by 2:30 p.m.

He was called by his employer at 5:00 p.m. and told to report to Bellaire, Texas, by noon 

on September 22 for an evacuation charter of elderly persons from a nursing home to 

Dallas. The driver went to work, fueled the motorcoach, ran an errand, and returned home 

by 7:30 p.m. He went to bed between 9:30 and 10:00 p.m.

On September 22, the driver awoke at 4:30 a.m. and departed Pharr, Texas, about 

5:00 a.m. He arrived at Brighton Gardens in Bellaire at 11:00 a.m. The driver then took a 

2-hour nap in the motorcoach and awoke when the nursing staff began loading the 

passengers around 1:30 p.m. The driver departed the nursing home between 3:00 and 3:30 p.m.

He continued driving for over 15 hours, in heavy evacuation traffic, until the fire occurred 

about 6:00 a.m. the following morning. (See figure 9.23)

The FMCSA, in 49 CFR 395.5, requires that no motor carrier shall permit or 

require any driver to drive a passenger-carrying commercial motor vehicle, nor shall any 

such driver drive a passenger-carrying commercial motor vehicle: (a)(1) more than 10 

hours following 8 consecutive hours off duty; or (a)(2) for any period after having been on 

duty 15 hours following 8 consecutive hours off duty. Title 49 CFR 395.1 guidance states 

that, under 395.1(b)(2), in case of any emergency, a driver may complete his/her run 

without being in violation of the provisions of the regulations in this part, if such run 

reasonably could have been completed absent the emergency. The Governor of Texas 

issued a proclamation on September 23, 2005, exempting the hours-of-service violations 

for all carriers and drivers involved in, and caught in, the hurricane evacuation.

22 The FMCSA requires that a discrepancy noted on the inspection report be corrected by the motor 

carrier within 15 days (49 CFR 396.9(d)). The owner of Global stated to the Safety Board that he did not 

furnish the FMCSA with documentation of correction to discrepancies noted during roadside inspections, as 

required.

23 This 72-hour history is based on the three interviews with the accident driver and interviews with 

Brighton Gardens staff.
Figure 9. Motorcoach driver’s 72-hour history.

DAYLIGHT NIGHT

060007000800 0900 1000 1100 1200 1300 1400 1500 1600 1700 1800 1900 2000 2100 2200 2300 2400 0100 0200 0300 0400 0500 

9/19 

9/20 

9/21 

9/22 

9/23 

 

Driving Sleeping On Duty/Not Driving Time of Incident 

Factual Information 15 Highway Accident Report

Vehicle Information

The 1998 54-passenger Motor Coach Industries, Inc. (MCI), model 102EL3 

“Renaissance” motorcoach was 45 feet long. It was equipped with a Detroit Diesel 

Corporation Series 60, 6-cylinder electronically controlled diesel engine and a Detroit 

Diesel Electronic Controls (DDEC)24 IV electronic control module (ECM). The ECM was 

damaged by the fire, which destroyed the recorded information. The motorcoach had an 

Allison Transmission model B-500R automatic transmission. A repair invoice for the 

motorcoach, dated September 14, 2005—9 days before the accident—showed an odometer 

reading of 505,608 kilometers25 (313,477 miles). The fire destroyed the odometer.

The motorcoach was equipped with three ArvinMeritor-manufactured axles: the 

front or steering axle, the second or drive axle, and the tag axle. The motorcoach had air 

brakes at all six wheel positions. The brakes were D-LISA air disc brakes, also 

manufactured by ArvinMeritor, while the six-channel antilock brake system (ABS) was 

manufactured by Meritor WABCO.

Seven windows were located along each side of the motorcoach. The windows 

were double-glazed safety glass; the exterior pane was tempered safety glass, and the 

interior pane was laminated safety glass. Six windows on each side were designed for 

emergency egress. Interlocking extrusions at the top frame provided hinge action for the

24 The DDEC IV ECM is capable of recording vehicle speed, brake application, engine rpm, and other 

information for more than 1 minute prior to a final stop of the vehicle.

25 The odometer recorded kilometers because this vehicle was originally built for, and owned by, a 

Canadian company.
Factual Information 16 Highway Accident Report

window sash assembly. The motorcoach was equipped with a 5-pound dry chemical 

ABC26 fire extinguisher, as required by 49 CFR 393.95.27

The motorcoach fuel tank was located aft of the luggage compartment and forward 

of the (rear) wheel well area. Two flexible thermoplastic fuel lines served as the supply 

and return paths from the fuel tank to the engine compartment. The fuel lines were made 

of Synflex composite fuel tubing, which is a flexible thermoplastic product with a nylon 

liner. The fuel lines, along with the power steering and coolant lines, ran within a 

centerline trench located between the left- and right-rear wheel wells, beneath the 

passenger cabin floor. Each fuel line is a nonreinforced seamless tube, designed and tested 

for use with noncrimp barbed fittings and rated for use with diesel fuel at a temperature 

range of –50o to +250o Fahrenheit (F).

The motorcoach seats consisted of upholstery-covered, foam-padded backs and 

cushions over steel seat frames. The floor was 0.5-inch-thick plywood with a 0.1-inchthick vinyl covering. Overhead luggage racks were constructed of aluminum, acrylonitrile 

butadiene styrene, and polyvinyl chloride (PVC) extruded handles. The ceiling at the front 

and rear window areas was fiberglass-reinforced plastic, and the main ceiling was Xorel 

FR28 over acrylonitrile butadiene styrene. The HVAC system was symmetrical along the 

centerline of the motorcoach. The return ducts were located at floor level, spanning the 

length of the vehicle; vent grills drew air into the return ducts.

Tag Axle

The third axle is mounted to the frame of the motorcoach by means of an 

adjustable air suspension system. This auxiliary weight-bearing axle is commonly referred 

to as the tag axle. A hub affixed to both the left and right sides of the outer axle assembly 

serves as the interface, allowing the wheels to rotate. (See figure 10.) In vehicles equipped 

with a disc brake rotor, such as the accident motorcoach, the brake rotor is also mounted 

on the hub. At the Safety Board public hearing on this accident, on August 8–9, 2006, in 

Washington, D.C. (see appendix A),29 a chief engineer with Timken Company (a bearing 

manufacturer) explained that a vehicle’s wheel bearings have three functions: to allow 

rotation with minimum friction (between wheel assembly parts), to carry the vehicle load 

26 A class A fire involves ordinary combustibles, such as wood, paper, cloth, rubber, and many plastics; 

a class B fire involves flammable liquids, oils, greases, tars, oil-based paints, and flammable gases; and a 

class C fire involves energized electrical equipment. A multipurpose dry chemical ABC fire extinguisher 

covers these types of fires and works by blanketing the fuel (burning materials) and interrupting the 

chemical chain reaction at the fuel’s surface. To a lesser extent, it dilutes the oxygen content of the air 

around the fire and absorbs heat. See <www.ehs.umb.edu/drychm.htm>, October 23, 2006.

27 A power unit that is not used to transport hazardous materials (HM) must be equipped with either a 

fire extinguisher having an Underwriters Laboratories Inc. (UL) rating of 5 B:C or greater, or two fire 

extinguishers, each with a UL rating of 4 B:C or greater.

28 Xorel FR is a fabric woven from polyethylene and treated with a fire retardant.

29 “Motorcoach Accident and Selected Federal Motor Carrier Safety Administration Oversight Issues, 

Wilmer, Texas.” The Safety Board may hold a public hearing as part of its investigation into an accident to 

supplement the factual record. Technical experts are called as witnesses to testify, and Board investigative 

staff and designated representatives from the parties to the investigation ask questions to obtain additional 

factual information. A hearing is not intended to analyze factual information for cause.
Factual Information 17 Highway Accident Report

or transfer the load (the weight of the motorcoach), and to concentrically position and 

align rotating and stationary components within the hub and wheel assembly. The wheel 

bearing rollers are evenly spaced and held within a circular wheel bearing cage, both of 

which are located inside a wheel bearing cup. The inner wheel bearing cup is fixed on the 

axle spindle (see figure 11), and the outer bearing cup is pressed into the hub. The inner 

cup remains stationary while the outer cup rotates with the hub and wheel.

Figure 10. Simplified hub and wheel diagram.

Tire

Wheel

Hub

Figure 11. Hub and wheel bearing diagram.

Axle

spindle

Rotor

Oil

seal

Inner

bearing

Inner

bearing cup

Hub

Outer

bearing cup

Outer bearing

Hubcap

Lockwasher

Oil

fill plug

Gasket
Factual Information 18 Highway Accident Report

The accident motorcoach had oil bath bearings; in this type of wheel bearing 

configuration, the individual bearing components are partially immersed in an oil 

lubricant (rather than being “packed” with grease) contained in a sealed reservoir within 

the wheel and hub. Oil is distributed to the bearings and throughout the reservoir cavity 

only when the vehicle is in motion. This distribution of oil provides both lubrication and 

cooling to the bearing rollers. A wheel bearing seal keeps the lubricant inside the bearing 

and the contamination outside.

The hubcap,30 the outer component on the axle assembly, contains a sight glass and 

filler plug and also functions as part of the reservoir for the wheel lubrication fluid. A 

mechanic or driver uses the sight glass to check the lubrication oil level for the wheel 

bearings. Oil is added by removing the filler plug. A wheel bearing may fail prematurely as a 

result of loss of lubrication, contamination of lubricant, improper wheel bearing adjustment, 

or incorrect adjustment during servicing or installation of new bearings. The most common 

reason for loss of lubrication is a worn-out or defective wheel seal; other causes may be a 

defective gasket between the hubcap and hub or a missing or improperly secured filler cap.

According to MCI, other than checking oil lubrication levels using the sight glass, 

oil leaks from wheel seals in the tag axle can be observed only from underneath the 

motorcoach because the wheel is mounted to the vehicle with its convex center facing 

outside.31 The MCI maintenance manual for the accident motorcoach specifies that the 

wheel bearing lubricating oil levels should be checked daily, and oil should be added if it 

is not visible at the sight glass level mark.32 The manual provides additional instructions 

for maintenance of wheel bearings, including specific warnings in text boxes to exercise 

caution when providing vehicle maintenance. (See figure 12.)

During a Safety Board interview, the motorcoach driver stated that he knew how 

wheel bearings were lubricated, though he had never lubricated them himself and had 

never checked the wheel bearing oil level on any motorcoach.

Vehicle Ownership

The accident motorcoach was titled (and registered) in British Columbia, Canada, 

to the owners of R&J McMynn Leasing (McMynn). MCT Charter Tours (MCT), of 

Beltsville, Maryland, leased the accident motorcoach. According to McMynn, the lessee is 

responsible for all vehicle repairs and maintenance, and the lease requires maintenance at 

specific mileage intervals. The lease also prohibits the sublease of the vehicle without 

authorization. MCT subleased the motorcoach to Global in May 2005; according to 

McMynn, the company was unaware of the sublease. U.S. Customs documents indicate 

that the motorcoach entered the United States from Canada near Buffalo, New York, on 

May 28, 2005. The motorcoach was not registered in the United States at the time of the 

accident, though registration was required.

30 According to MCI, this model of motorcoach is originally equipped with aluminum hubcaps on the 

tag axle; on the accident motorcoach, the 3R hubcap was aluminum, and the 3L hubcap was steel.

31 The concave outside wheel mounting is common for steer axles in trucks and motorcoaches and for 

the tag axle in all motorcoaches.

32 MCI 102E Series Maintenance Manual.
Figure 12. Example of MCI maintenance manual warning text box.

Coach wheels weigh more than 200 lbs (90 kg.) To avoid

injury, use extreme care when removing them. 

WARNING

Factual Information 19 Highway Accident Report

During a Safety Board interview with Global’s owner on September 26, 2005, he 

stated that he had an insurance card (required) for the accident motorcoach and that it did 

undergo a commercial vehicle inspection on June 9, 2005, at Valley Volvo in Pharr, 

Texas. The owner reported that he used a 144-hour temporary permit33 for the 

motorcoach during its operation in Louisiana in post-Katrina relief efforts, as well as 

during the Brighton Gardens evacuation trip from Bellaire to Dallas. The permit had 

expired during the post-Katrina relief operations in Louisiana. According to the 

motorcoach driver, who had driven the same vehicle in Louisiana, he removed a tag 

(license plate) from another Global vehicle and attached it to the accident motorcoach34

to avoid being stopped for an expired registration.

Accident Motorcoach Maintenance. The following maintenance information is 

available for the accident vehicle beginning in May 2005 with the sublease arrangement 

between MCT and Global. The owner of Global said that he does not have a mechanic or 

brake inspector on staff full-time and that he normally takes his vehicles to a dealership or 

service center for repairs. About 3 weeks prior to the accident, he had hired a mechanic to 

perform oil changes, minor repairs, and belt changes, but the mechanic worked only parttime on Saturdays. Global did not have a brake inspector qualification file for the 

mechanic, as required by 49 CFR 396.25. The motorcoach had undergone preventative 

maintenance35 August 8–12, 2005, at Valley Volvo, in Pharr, Texas. According to the 

mechanic who performed the maintenance, he checked the oil level in the hubs and 

checked for oil around the wheels but did not find any leaks.

33 The Texas 144-hour permit specifies: “this permit is issued to vehicles owned by residents of the 

United States, Mexico, or Canada subject to registration by the State of Texas and which are not authorized 

to travel on the public roads of the State for lack of registration.”

34 Postaccident, inside a luggage compartment, police found a Texas temporary license plate, expiring 

September 8, 2005, with a vehicle identification number (VIN) matching the accident motorcoach VIN.

35 The preventative maintenance included oil change and filter, fuel filter change, check of air cleaner, 

greasing of fittings, and check of rear differential oil level and other fluid levels, in addition to a 

transmission fluid and filter change, winterization and repair of radiator, and compressor head gasket repair.
Factual Information 20 Highway Accident Report

The FMCSA requires motor carriers to ensure that every driver prepare a written 

driver vehicle inspection report (DVIR) at the completion of each day on each vehicle 

operated and further requires that the report list any defects noted during operation of the 

vehicle.36 When interviewed by the Safety Board on September 26, 2005, Global’s owner 

stated that he paid drivers by the mile and did not pay them to conduct pretrip or posttrip 

vehicle inspections.

Postaccident Inspection of Tag Axle. During the Safety Board’s postaccident 

investigation, the left and right tag axle wheel components were inspected because the fire 

had originated in the right-side tag axle wheel well. The left-side tag third (3L) axle wheel, 

hub, and brake assembly and other related components were examined. The rubber fill cap 

or fill plug, where oil is put into the hub cavity to lubricate the wheel bearings, was missing, 

and a significant amount of water was found in the hub cavity. The 3L wheel bearing hub 

cavity was low on lubricant, with only residual traces of oil on the bearing elements, though 

the bearings were intact, in good condition, and did not show signs of wear or excessive 

heat. The 3L ABS tone ring component and adjoining axle torque plate were encrusted with 

oil, which, along with the low oil level in the hub cavity, is an indication of oil leaking from 

the wheel seal. At the Safety Board public hearing, the senior technical advisor for MCI 

said that inspection of the accident motorcoach left tag axle knuckle and torque plate 

showed that they were heavily coated in oil and dirt, indicating “that there had been at least 

for some considerable period of time, a fairly heavy oil leak.”

The inspection revealed that the right-side tag axle (3R) aluminum hubcap melted 

during the fire; several small fragments were still present around the hubcap mounting 

bolts. (Aluminum melts at approximately 1,150o F.) The 3R tire was burned, and no rubber 

remained. The 3R brake rotor was skewed outward and was in contact with the torque plate 

and the brake caliper housing. Normally, the brake rotor does not make contact with either 

of these components. This abnormal contact caused grinding marks on the underside of the 

caliper housing, as well as on the torque plate and brake rotor. Additionally, the brake pad 

retaining clips, which are normally round, had flat spots from contact with the rotor; the 3R 

outside brake pad was worn more on the top, and the 3R inside pad was worn heavier at the 

bottom, consistent with wear from the displaced and tilted rotor.

As originally installed, the outer wheel bearing contains 19 rollers evenly spaced 

and held within a bearing cage. (See figure 13.) Inspection of the 3R wheel bearing 

revealed four flattened rollers in the hub. Two other flattened rollers were found in the 

area of the grass fire, near MP 266. The inner wheel bearing, as originally installed, 

contained 17 rollers. Eight or nine rollers were discovered fused together, two other rollers 

were found severely flattened, and the bearing cage was destroyed. (See figure 14.) The 

inner wheel seal was destroyed. According to a chief engineer with Timken Company, the 

36 In accordance with 49 CFR 396.11, the DVIR shall cover at least the following parts and accessories: 

service brakes, including trailer brake connections; parking (hand) brake; steering mechanism; lighting 

devices and reflectors; tires; horn; windshield wipers; rear vision mirrors; coupling devices; wheels and 

rims; and emergency equipment. The report shall identify the vehicle and list any defect or deficiency 

discovered by or reported to the driver that would affect safe operation of the vehicle or result in its 

mechanical breakdown.
Factual Information 21 Highway Accident Report

strength of wheel bearing roller material is a function of temperature. At a temperature as 

low as 1,000o F, the roller material can begin to lose metal strength. Further, the amount of 

roller deformation is dependent on the loading (weight) from the motorcoach and the 

length of time the roller is exposed to this weight and increased temperatures.

Figure 13. Left tag axle outer wheel bearing assembly.

Figure 14. Damaged right tag axle spindle and inner bearings.
Factual Information 22 Highway Accident Report

Vehicle Fires

Motorcoach Fire Data Sources

During the investigation of this accident, the Safety Board compiled data in an 

attempt to examine the scope of motorcoach fires in the United States. The Safety Board 

examined two insurance company databases and two passenger motor carrier company 

reports for vehicle fire information. In addition, the Safety Board gathered motorcoach 

and bus fire data from several sources, including Federal accident reporting databases 

such as the National Highway Traffic Safety Administration (NHTSA) Fatality Analysis 

Reporting System (FARS)37 and General Estimates System (GES) and other sources, 

including the FMCSA Motor Carrier Management Information System38 (MCMIS) and 

the National Fire Protection Association (NFPA) vehicle fire database. Vehicle reporting 

requirements for each source (MCMIS, FARS, GES, and the National Fire Incident 

Reporting System [NFIRS]) are different and do not allow the correlation of 

comprehensive and statistically accurate data on motorcoach fires. Each DOT agency 

defines “bus” and “motorcoach” differently for data collection and analysis, and this 

terminology is also different in the NFIRS database.

The Federal Motor Carrier Safety Regulations (FMCSRs) and the vehicle 

classification in the MCMIS database define a bus in two ways: as any motor vehicle, 

including taxicabs, designed, constructed, or used for the transportation of passengers 

(49 CFR 390.5) and as any vehicle designed to carry more than 15 passengers, 

including the driver (49 CFR 393.5). NHTSA’s FARS database uses five body type 

classifications for buses: intercity/cross-country bus, school bus, transit bus, other bus, 

and unknown bus. The FARS and GES databases are populated with police-reported 

accident data.39

The FMCSA reports40 that FARS data from 1994–2004 include 24 motorcoach 

fires with fatalities; GES data from 1995–2003 include two motorcoach accidents that 

involved fires. The FMCSA also reports that its MCMIS data from 1995–2005 include 

265 motorcoach fires, of which 4 involved fatalities, 49 involved injuries, and 212 

involved property damage. On March 2, 2006, the then-FMCSA Administrator, during 

37 FARS was established in 1975 and contains data on fatal traffic accidents in the 50 States, the District 

of Columbia, and Puerto Rico. To be included in FARS, an accident must involve a motor vehicle traveling 

on a road open to the public and result in the death of a person within 30 days.

38 The MCMIS is a database of motor carrier census information, inspections, accidents, and 

enforcement history.

39 Police agencies use the American National Standards Institute (ANSI) definitions of motor vehicle 

accidents and traffic accidents. ANSI defines a motor vehicle accident as a transport accident that involves a 

motor vehicle in transport and a traffic accident as a road vehicle accident in which the unstabilized situation 

originates on a trafficway or a harmful event occurs on a trafficway. American National Standards Institute, 

Manual on Classification of Motor Vehicle Traffic Accidents, ANSI D16.1-1996 (Washington, DC: ANSI, 

1996) Sections 2.4.12 and 2.4.18.

40 U.S. Department of Transportation, Research and Innovative Technology Administration, Volpe 

National Transportation Systems Center, Motorcoach Fire Safety Analysis Work Plan, Project No. CV702 

(Cambridge, MA: Volpe National Transportation Systems Center, 2006) 1.
Factual Information 23 Highway Accident Report

testimony to the House Committee on Transportation and Infrastructure Subcommittee on 

Highways, Transit, and Pipelines, explained that bus fires have been found to be a chronic 

problem throughout the entire industry.41

During the Safety Board’s public hearing, the NFPA’s manager of fire analysis 

services stated that the NFIRS data from 1999–2003 indicated an average of 2,200 bus 

fires each year (including transit42 and school buses), or about 6 per day. A National 

Interstate Insurance Company representative testified that insurance data from 2003–2006 

showed 74 bus fire claims, including school buses, transit buses, and motorcoaches. A 

Lancer Insurance Company representative reported 220 bus fire claims from 1998–2005. 

During the week of October 23, 2006, the Safety Board had access to additional 

information on 80 of these claims (29 wheel/tire fires, 37 engine fires, and 14 other).43 Of 

the 29 wheel/tire fires, 5 were wheel bearing failures.

Two large self-insured passenger carrier companies volunteered information to the 

Safety Board regarding their experiences with vehicle fires. From 2004–2005, one 

company reported 24 motorcoach fires (6 axle/wheel, 14 engine compartment, 1 brake 

system, 2 tire, and 1 battery); the other company reported 49 motorcoach fires from 

January 2004–April 2005 (9 wheel bearing, 12 turbocharger, 14 electrical system, 11 

brake system, and 3 fuel system).

Volpe National Transportation Systems Center

The Volpe National Transportation Systems Center (Volpe Center) is conducting a 

motorcoach fire safety analysis for the FMCSA.44 The objectives of the study are

• To gather information on the causes, frequency, and severity of motorcoach 

fires and to identify ways to prevent, reduce, or mitigate their severity and 

frequency,

• To investigate and qualitatively assess fire suppression systems and their 

adequacy based on the type and location of fire,

• To assess the adequacy of current motorcoach operational inspection practices 

(both daily and periodic) as they relate to detecting and remedying situations 

that may lead to a fire,

41 See <testimony.ost.dot.gov/test/Sanberg1.htm>, May 4, 2006.

42 A transit bus is a vehicle that frequently loads and unloads passengers and operates primarily in local, 

scheduled route service at lower-than-highway speeds. These buses are manufactured with space and 

accommodations, such as support bars or hand-hold straps, for standing passengers.

43 Following the public hearing, Lancer invited the Safety Board to review a portion of its claim files 

for fire data.

44 Motor Coach Fire Safety Analysis Work Plan.
Factual Information 24 Highway Accident Report

• To consider and recommend fire prevention and mitigation techniques, to 

include revisions to both inspection and maintenance procedures, use of active 

fire suppression systems, use of passive systems to mitigate fire spread and 

release of toxic gases, and methods to facilitate the exit of passengers and 

drivers, and

• To set up a database for a broad population of motorcoach fires, identifying the 

characteristics and outcomes of incidents; the operational, usage, maintenance, 

and inspection characteristics of vehicles; and the correlating contributing and 

mitigating factors.

The Volpe Center expects to complete the final report in March 2007.

Tire Fires and Fire Suppression Systems

At the public hearing on this accident, the manager of the product analysis 

department of Bridgestone Americas Holding, Inc. (Firestone),45 stated that little 

information is available in the public domain about whole tire autoignition temperatures, 

and Firestone’s limited testing indicates that the tire temperature would approach 800o F 

before autoignition. He further stated that when a tire is subjected to an increasing amount 

of heat, approaching 350o–400o F, its rubber begins to break down and the tire does not 

maintain the desired material properties for adhesion, strength, or tear resistance. As long 

as the heat cycle continues, the tire will accelerate toward failure.

The vehicle fire suppression systems product manager with Amerex Corporation 

reported that rubber burns very hot, and modern tires generally have a steel cord that 

retains heat. In addition, the metal mass from the wheel itself (axles and brakes) retains 

heat, which can cause a reflash, even if the fire on the rubber portion of the wheel 

assembly is extinguished. He further added that if the sidewall is compromised as a tire 

burns, it is quite likely that the inside of the tire will get fresh air, and the tire will burn on 

both the outside and the inside. A fire extinguisher agent applied to the exterior of the tire 

may never reach the interior and will not fully extinguish the fire.

Automatic fire detection and suppression systems for engine compartment and 

electrical equipment fires have been installed on some transit and intercity 

motorcoaches.46 According to the senior technical advisor for MCI, the number of 

motorcoaches being sold with fire suppression systems has increased.47 Generally, these 

systems, typically located in the engine compartment, employ spot heat detectors and a 

fire suppression agent distribution network with individual nozzles. The systems are not 

designed to protect against and extinguish a tire fire.

45 Bridgestone Americas Holding, Inc., is the parent corporation to Bridgestone Firestone North 

American Tire, LLC, and other subsidiaries that manufacture tires in North America.

46 For example, New Jersey Transit has been using fire detection and suppression systems in its fleet 

since 1994.

47 In 2005, MCI also introduced the SmarTire pressure temperature monitoring system as an option for 

its motorcoaches. Although not a suppression system, it aids in the identification of high temperatures.
Factual Information 25 Highway Accident Report

The vice president of Daecher Consulting Group stated at the public hearing that 

some types of fires severely affect a motorcoach. He explained that engine fire 

suppression systems “tend to work fairly well in terms of recognizing the fire, controlling 

it.” However, he stated that “there is no way” motorcoach equipment will have any effect 

in putting out a tire fire or a fire that originates in a wheel well. He added that 

motorcoaches “go up very quickly” as a fire propagates.

The vehicle fire suppression systems product manager with Amerex Corporation 

explained that vehicle fires are of an “uncontrollable nature,” and the purpose of a 

suppression system is to delay or prevent the spread of a fire to give the occupants a 

reasonable amount of time to escape. He added that “the current thinking on tire fire 

protection, instead of extinguishment, is to prevent ignition, working toward a heat 

monitoring system that will give a prewarning to a driver in the event of elevated heat in 

one or more wheel wells.”

In July 2006, the FMCSA announced its fiscal year 2006 research grants program, 

as specified in the Safe, Accountable, Flexible, Efficient Transportation Equity Act: A 

Legacy for Users (SAFETEA-LU), Section 5513(a), and provided funding of $1.4 million 

for a roadside thermal imaging inspection system project. As reported in 71 Federal 

Register (FR) 42438–42439, the project

uses a thermal imaging inspection system that leverages state-of-the-art thermal 

imaging technology, integrated with signature recognition software, providing the 

capability to identify, in real-time, faults and failures in tires, brakes, and bearings 

mounted on commercial motor vehicles.

The objectives of the demonstration project are to employ the system in a field 

environment (such as along an interstate) to further assess its capability of identifying 

faults in tires, brakes, and bearings mounted on commercial motor vehicles; to establish 

the probability of failure; and to develop and integrate a predictive tool to identify an 

impending tire, brake, or wheel bearing failure and provide a timeframe in which the 

failure may occur.

In September 2006, the FMCSA awarded a grant for the demonstration project to 

the International Electronic Machine Corporation of New York; the period of performance 

is expected to be 24 months.

Highway Information

General

The motorcoach fire occurred on I-45 north, approximately 1,000 feet north of 

the exit ramp to Mars Road, at MP 269.5, near Wilmer, Texas. I-45 is classified as a 

rural principal arterial road; it is a divided, straight, and level six-lane concrete roadway. 

Each travel lane is 12 feet wide, and the lanes are separated by broken white 

retroreflective lines on the road surface. A solid yellow retroreflective line delineates 
Factual Information 26 Highway Accident Report

the inner edge of the roadway. A 24-foot-wide concrete median with a permanent 32-

inch-high median barrier separates the northbound and southbound lanes. A solid white

retroreflective line delineates the outer edge of the roadway from the 10-foot-wide outer

shoulder and the 12-foot-wide inner shoulder. The posted speed limit in the vicinity of

the fire location was 60 mph.

Traffic

According to records of the Texas Department of Transportation (TxDOT),48 the

most recent traffic count in the vicinity of the accident was 44,000 vehicles per day in

2003. During evacuation in advance of Hurricane Rita, TxDOT instituted contra-flow

lanes49 on I-45 north of Houston in anticipation of the estimated 2 million evacuees

traveling to other locations for safety. “Contra-flow” converted all lanes of I-45 to

northbound-only travel.

On September 22, 2005, all lanes on I-45 from Conroe to Fairfield, Texas (90 miles),

were designated one-way northbound. The contra-flow lanes did not extend as far north as

the location of the motorcoach fire, at MP 269.5. Witnesses reported that traffic in the

vicinity of the accident was moving freely, with vehicles traveling northbound at 40–50

mph. Table 2 shows a chronology of the date, time, and limits of the one-way northbound

operation for I-45.

Table 2. Contra-flow history on I-45 during Hurricane Rita evacuation.

Operations Information

Global Limo Inc.

According to the FMCSA registration, Global was an authorized interstate for-hire

passenger motor carrier50 headquartered in the State of Texas. At the time of the accident,

Global operated with four motorcoaches (not including the accident motorcoach) and six

drivers. According to Global’s owner, the company was established in 1980; the FMCSA

48 TxDOT records from 1998–2001 indicate that 201 accidents occurred within 5 miles of the site of the

motorcoach fire. The accidents (overturn, hit motor vehicle, pedestrian, parked car, animal, and fixed object)

resulted in 6 fatalities and 190 injuries.

49 Reverse-flow operation on a divided highway is termed “contra-flow.” American Association of

State Highway and Transportation Officials, A Policy on Geometric Design of Highways and Streets

(Washington, DC: AASHTO, 2004) 492.

Date (2005) Time I-45 traffic lane operation 

Sept 22 12:00 noon TxDOT working to improve traffic flow from Houston 

2:00 p.m. All lanes from Conroe to Fairfield, Texas (90 miles), 

routed one-way northbound

Sept 23 6:07 a.m. Time of motorcoach fire

50 DOT No. 1031282.
Factual Information 27 Highway Accident Report

records show that interstate operating authority was granted to Global on June 30, 1987. 

The owner changed the company name from Global Tours and Charters to Global Limo 

Inc. on November 20, 2003.

Company History. Global’s inspection selection system (ISS) value51 was 92, 

falling in the ISS-2 “inspection recommended” range of values. For the 2 years prior to the 

accident (September 23, 2003–September 23, 2005), Global’s drivers had been subjected 

to eight roadside inspections, which showed serious violations of the FMCSRs and 

resulted in four drivers being placed out of service (OOS); thus, the company’s OOS rate 

was 50 percent (the 2005 national OOS rate was 6.6 percent).52 The accident driver 

himself had undergone three roadside inspections53 prior to September 23 and had been 

placed out of service in two of the three inspections.

The four drivers were cited for multiple violations,54 which included:

• Failing to retain record of duty status (also known as a driver’s log) for the 

previous 7 days (OOS),

• Failing to maintain current record of duty status (OOS),

• Failing to meet CDL restrictions (OOS),

• Failing to show required information for total hours (violation), and

• Failing to have an English-speaking driver (violation).

Also during the 2 years prior to the accident, four of Global’s vehicles were 

subjected to roadside inspections, and vehicle defects55 were found. None of Global’s 

vehicles were placed out of service during this period (the 2005 national OOS rate was 

23.4 percent).

Compliance Reviews. On April 10, 2002, the TxDPS conducted an intrastate 

educational review of Global; this review is similar to the FMCSA compliance review. At 

the time of the review, the State of Texas did not issue safety ratings to intrastate carriers; 

it began doing so in early 2004.56 (The FMCSA is the only agency that issues safety 

ratings to interstate carriers.)

51 The FMCSA’s ISS program is designed to aid roadside inspectors in selecting vehicles for individual 

inspection. Inspections are optional for carriers with inspection values from 50–74; carriers with inspection 

values less than 50 are not considered for inspection under normal circumstances.

52 According to the FMCSA, the fiscal year 2004 OOS rate for commercial bus drivers was 5.1 percent, 

and the OOS rate for commercial buses was 9.5 percent.

53 February 12, March 1, and August 19, 2005.

54 A “violation” is a violation of the FMCSRs found during the inspection and recorded. A serious 

violation results in an OOS order because the violation must be corrected before the affected driver or 

vehicle can return to service.

55 These defects included inoperable tail lamp, no required vehicle markings, no fire extinguisher, 

insufficient tire tread depth on steer axle, inoperable marker lamp, defective brake warning device, operating 

a commercial motor vehicle without a periodic inspection, and damaged windshield.

56 The TxDPS issues OOS orders to carriers that are rated “unsatisfactory.” Shutdown orders are issued 

after 60 days for passenger carriers and HM carriers and after 75 days for property carriers.
Factual Information 28 Highway Accident Report

The TxDPS procedures used in the safety review process mirror the FMCSA 

compliance review process. The educational review of Global listed the following 

deficiencies:

• No drug and alcohol testing program,

• No driver background investigation,

• No driver employment application,

• No driver record inquiry,

• Failure to require driver to make a record of duty status,

• Failure to require form and manner on driver’s log,

• Failure to maintain vehicle inspection and maintenance records, and

• Failure to maintain evidence of brake inspector qualifications.

The April 2002 educational review resulted in five specific recommendations for 

compliance in the areas of driver qualifications, driver logs, and vehicle maintenance. 

Global was directed to notify the TxDPS of its actions to comply with the FMCSRs. The 

narrative section of the review included additional comments describing the discrepancies 

in each area. The reviewing TxDPS officer recommended compliance monitoring of 

Global and a followup review. The followup review did not take place.

The FMCSA conducted an on-site compliance review of Global on February 6, 2004,

noting seven violations of 49 CFR Parts 382, 391, 395, and 396.57 (See appendix B for a list 

of these violations.) The FMCSA issued a satisfactory rating to Global on February 12, 2004.

Following this review, Global’s vehicles and drivers underwent seven roadside inspections 

prior to the accident, which resulted in three driver OOS violations (the accident driver 

accounted for two of the three) of the FMCSRs for logbook and duty status.

After the accident, the FMCSA conducted another compliance review of Global, 

which included inspection of Global’s four remaining motorcoaches. Two of the 

motorcoaches were placed out of service, resulting in a 50 percent OOS rate. The national 

OOS rate in 2005 was 23.4 percent. The FMCSA issued an unsatisfactory rating to Global 

on October 7, 2005, stating that the compliance review uncovered violations of the 

FMCSRs (49 CFR Parts 382, 391, 395, and 396) “so widespread as to demonstrate a 

continuing and flagrant disregard for compliance” and a management philosophy 

“indifferent” to motor carrier safety. Table 3 summarizes the violations common to both 

compliance reviews. (See appendix B for a full list of the violations found in each 

compliance review.)

57 Prior to 2004, the FMCSA reported that Global had been identified as a category B carrier within the 

Safety Status Measurement System (SafeStat), which is used to identify and prioritize carriers for FMCSA 

safety improvement and enforcement programs, such as compliance reviews. SafeStat places carriers in 

categories A–H, with “A” as the lowest safety fitness assessment. At the time of the accident, Global had 

been categorized as an “E” carrier, which indicated that the company had a driver safety evaluation area 

(SEA) value of 75 or greater (Global’s value was 96.96) and all other SEA values were less than 75. (See 

appendix C for more details on SafeStat values.)
Factual Information 29 Highway Accident Report

Table 3. Global compliance review violations, February 2004 and October 2005.

In Global’s postaccident compliance review, the FMCSA declared that the

company presented an “imminent hazard” to public safety and issued an operations OOS

order on October 7, 2005. The FMCSA had determined that the violations detected in the

compliance review both individually and cumulatively were likely to result in serious

injury or death to Global’s drivers and the motoring public. The OOS order was based on

determinations that Global’s vehicles were mechanically unsafe due to lack of vehicle

maintenance, inspections, and repairs and that the company failed to comply with Federal

regulations on drug and alcohol testing, driver qualifications, and hours of service.

Federal Motor Carrier Safety Administration

General. The FMCSA was established as a separate administration within the

DOT on January 1, 2000, pursuant to the Motor Carrier Safety Improvement Act of 1999.

Its primary mission is to reduce accidents, injuries, and fatalities involving large trucks

and buses. According to the FMCSA, the agency develops and enforces data-driven

regulations and uses safety information systems to focus on higher risk carriers. The

FMCSA requires a motor carrier to have management controls that comply with

applicable safety requirements and uses a rating formula to determine a motor carrier’s

safety fitness. The FMCSA mission is primarily accomplished through on-site compliance

reviews and roadside program inspections of a carrier’s vehicles and drivers.

Compliance Reviews. The FMCSA standards require a motor carrier to have

adequate controls in place to ensure compliance with the FMCSRs. In accordance with

49 CFR Part 385, appendix B, one step in the safety rating process is an FMCSAconducted compliance review. (See appendix D for more details.)

During a compliance review, the FMCSA uses the computer program CAPRI58 to

organize and record compliance information and determine the proposed safety rating.59

The compliance review applies six factors (general, driver, operational, vehicle, hazardous

materials [HM], and accident rate) to determine the degree to which a carrier complies

with the FMCSRs and meets the Federal safety fitness standard. Within each factor, the

FMCSR violation Feb 6, 2004 Oct 7, 2005 CFR

Failure to provide drivers with drug and alcohol 

policies

X X 49 CFR 382.601(a)

Failure to have persons trained for reasonable 

suspicion testing

X X 49 CFR 382.603

False reports of records of duty status X X 49 CFR 395.8(e)

Failure to maintain a note relating to annual 

review of driver’s driving record

X X 49 CFR 391.51(b)(5)

58 Compliance Analysis and Performance Review Information System.

59 The compliance review itself is conducted at the carrier’s business location; the actual safety rating is

determined and issued by the FMCSA headquarters in Washington, D.C.
Factual Information 30 Highway Accident Report

FMCSRs are rated as either acute60 or critical61 regulations, in accordance with 49 CFR 

Part 385, appendix B II(b); the carrier’s noncompliance results in an assessment of one 

point for that factor.62 According to the FMCSA, noncompliance with acute regulations 

and patterns of noncompliance with critical regulations are quantitatively linked to 

inadequate safety management controls and usually higher-than-average accident rates.63

(On May 28, 1997, the FMCSA published a request for comments on a change to the 

safety fitness ratings in appendix B to Part 385 and made it an interim measure. In 

November 1997, the appendix was made an interim final rule pertaining to the compliance 

review process.64) Once the compliance review is finished and violations or deficiencies 

(the number of acute or critical regulations not complied with by the carrier) are tallied, a 

safety rating is computed for each applicable factor. As defined below, each factor is rated 

“satisfactory,” “conditional,” or “unsatisfactory,” except the accident factor, which is rated 

either “satisfactory” or “unsatisfactory”:

• A satisfactory rating indicates that the carrier has not violated any acute 

regulations or shown a pattern of noncompliance with critical regulations.

• A conditional rating indicates that the carrier has violated one acute regulation 

or has a pattern of noncompliance with critical regulations.

• An unsatisfactory rating indicates that the carrier has violated two or more 

acute regulations or has a pattern of noncompliance with two or more critical 

regulations.

According to the FMCSA, an accident rate below 1.5 per million miles is 

considered satisfactory; anything higher is rated “unsatisfactory.”65 The ratings for all six 

factors are given equal weight and entered into a rating table. Table 4 summarizes the 

FMCSA rating process.

60 Acute violations of the FMCSRs (or HM regulations) are defined as those that demand immediate 

corrective action, such as requiring or permitting the operation of an OOS vehicle before repairs are made, 

regardless of the motor carrier’s overall safety posture.

61 Critical violations indicate deficiencies in the motor carrier’s management controls, such as requiring 

or permitting a driver to drive after having been on duty for 15 hours (49 CFR 396.9(c)(2)).

62 Two points are assessed for noncompliance with a “critical” regulation in 49 CFR Part 395 for hours 

of service.

63 See <www.fmcsa.dot.gov/rules-regulations/administration/fmcsr/385appnb.htm>, December 13, 2006.

64 By this interim final rule, the Federal Highway Administration (FHWA) publishes its safety fitness 

rating methodology as appendix B to 49 CFR Part 385 to be used as an interim measure until a notice of 

proposed rulemaking (NPRM) becomes final (Docket No. MC-94-22 changed to FHWA-97-2252). See 62 

FR 28807.

65 The rating for the accident factor is based on the number of recordable accidents in relation to the 

carrier’s annual mileage for the 12 months leading to the compliance review. The FMCSA defines a 

recordable accident as an occurrence involving a commercial motor vehicle operating on a public road in 

interstate or intrastate commerce that results in a fatality, a bodily injury, or a vehicle incurring disabling 

damage that requires it to be towed from the scene (49 CFR 390.5). The accident threshold for a satisfactory 

rating is 1.7 per million miles for carriers operating within 100 air miles of their home terminal (49 CFR Part 

385, appendix B, (B) accident factor (d)).
Factual Information 31 Highway Accident Report

Table 4. Motor carrier safety ratings.

The rating table establishes the motor carrier’s overall final safety rating:

satisfactory, conditional, or unsatisfactory. A safety rating is issued to a motor carrier within

30 days of the completion of a compliance review. When the FMCSA issues a proposed

safety rating of unsatisfactory, it is a notice to the motor carrier that the FMCSA has made a

preliminary determination that it is “unfit” to continue operating in interstate commerce and

that the prohibitions in 49 CFR 385.13 will be imposed after 45 days for passenger-carrying

operations, if necessary safety improvements are not made. According to 49 CFR

385.13(a), an owner or operator receiving notice of a proposed unsatisfactory safety rating

from the FMCSA must improve that rating to conditional or satisfactory within 45 days of

the date of notice. Owners or operators who fail to improve their ratings within this 45-day

period are prohibited from operating in interstate commerce beginning on the 46th day

following the date of the rating notice and may not reestablish interstate operations until

they become fit for such transportation. (See appendix C for more information.)

According to the FMCSA, 910,866 motor carriers were operating in the United

States in calendar year 2005, and the agency conducted compliance reviews on 8,097

carriers. Table 5 shows the results of these reviews. Overall, of 61,924 violations

discovered during the 8,097 compliance reviews, 53,064 were noncritical and nonacute

and are not used to rate the carrier.

In September 2005 and again in June 2006, the Safety Board met with the FMCSA

to discuss FMCSA plans for evaluating the compliance review process as part of the

Comprehensive Safety Analysis (CSA) 2010 Initiative. According to the FMCSA, the

CSA 2010 Initiative is an effort to evaluate the effectiveness of current Federal safety

compliance and enforcement programs, such as compliance reviews and roadside

inspections, and to identify better methods of achieving an accident-free environment. The

FMCSA indicated that the evaluation is still in its early stages, no conclusions have been

reached, and it is too soon to speculate on what specific changes may be made in the safety

rating process. Full implementation of any changes proposed by the initiative is not

expected until 2010.

No. of factors with 

unsatisfactory 

ratings

No. of factors with 

conditional ratings Safety rating

0 2 or less Satisfactory

0 More than 2 Conditional

1 2 or less Conditional

1 More than 2 Unsatisfactory

2 or more 0 Unsatisfactory
Factual Information 32 Highway Accident Report

Table 5. FMCSA compliance review data, 2005.

The FMCSA has posted on its website information explaining the CSA 2010

Initiative.66 According to the posting, the initiative is “a comprehensive review and analysis

of FMCSA’s current commercial motor vehicle safety compliance and enforcement

programs.” The FMCSA’s objective is to develop and deploy a new operational model to

identify drivers and operators that pose safety problems and to intervene to address those

problems.67 The FMCSA acknowledges that the present compliance review program is

resource-intensive and reaches only a small percentage of motor carriers68 and that

increased attention needs to be given to commercial vehicle drivers.

Roadside Inspection. According to the FMCSA, in this program, qualified safety

inspectors carry out roadside inspections in accordance with the North American Standard

Inspection Program Guidelines, which were developed by the Commercial Vehicle Safety

Alliance (CVSA) and the FMCSA. The ISS-2 “value” based on safety is derived from a

carrier’s roadside inspections and accident history. According to the program, vehicles

with an inspection value of 75–100 (maximum value is 100) should be inspected.69

During roadside inspections,70 an inspector examines commercial motor vehicles

and their drivers to determine whether they meet the FMCSRs. Under the North American

Standard inspection criteria, a leaking wheel seal alone is not an OOS item; it is an OOS

item if the hubcap is missing or broken, allowing an open view into the hub assembly, or if

the wheel is smoking due to bearing failure.71 Serious violations found during roadside

Safety rating No. of reviewsA

Percent of total 

reviews

Satisfactory 5,234 64.6

Conditional 2,117 26.1

Unsatisfactory 531 6.6

Not rated 215 2.7

Total 8,097 100

A

See MCMIS March 31, 2006, snapshot, <ai.fmcsa.dot.gov/ProgramMeasures/CR/NR/NSR/ 

Report.asp?FC=C&RF=T.>, October 20, 2006.

66 See <www.fmcsa.dot.gov>, December 12, 2006.

67 See <www.fmcsa.dot.gov/safety-security/safety-initiatives/csa2010/csa2010listening.htm?>,

December 12, 2006.

68 In calendar year 2005, less than 1 percent of the 910,866 registered motor carriers underwent

compliance reviews (8,097 reviews conducted).

69 Inspections are optional for carriers with inspection values from 50–74; carriers with inspection

values less than 50 are not considered for inspection under normal circumstances.

70 Most roadside inspections are conducted by States through the FMCSA-administered grant Motor

Carrier Safety Assistance Program.

71 Commercial Vehicle Safety Alliance, North American Standard Inspection Program Guidelines,

Out-of-Service Criteria, sections 12.i(1), (2) (Washington, DC: CVSA, 2005).
Factual Information 33 Highway Accident Report

inspections result in the issuance of driver or vehicle OOS orders; these violations must be 

corrected before the affected driver or vehicle can return to service. According to the 

FMCSA, 3,022,286 roadside inspections were conducted in 2005;72 2,960,849 driver 

inspections resulted in 195,667 driver OOS violations, and 2,198,718 vehicle inspections 

resulted in 513,439 vehicle OOS orders.

Nursing Home Information

The Brighton Gardens senior assisted living center, located in Bellaire, Texas, 

offers assisted living services, nursing and rehabilitation services, and hospice care. 

Sunrise operates more than 420 senior living communities in 37 States, the District of 

Columbia, Canada, the United Kingdom, and Germany, with a combined resident capacity 

of 52,000. Sunrise offers at-home assisted living, independent living, assisted living, 

Alzheimer’s care, and nursing and rehabilitative care.73

During the public hearing for this accident, Sunrise officials stated that the 

company had originally planned to use a shelter-in-place strategy at Brighton Gardens 

during the Hurricane Rita emergency. Sunrise made the decision to evacuate in the 

evening hours of September 21, 2005, at the urging of the Bellaire fire marshal. Those 

residents who could not be accommodated locally were to be transferred to facilities 

in Arlington and Dallas, Texas.

Several Sunrise nursing home and assisted living facilities in the Gulf region 

required evacuation in advance of Hurricane Katrina, which made landfall in New 

Orleans, Louisiana, on August 29, 2005. During those preparations, Sunrise had contacted 

BusBank to secure motorcoach transportation to evacuate residents in two coastal 

Louisiana communities. According to Sunrise representatives at the public hearing, the 

company did not encounter any problems with the buses provided by BusBank.74

Sunrise owned small wheelchair-accessible shuttle buses that were normally used 

for short day trips but were not equipped with restrooms. After watching media coverage 

of the heavy evacuation traffic, which showed evacuee vehicles running out of gasoline, 

Sunrise representatives made the decision to charter a diesel-powered motorcoach with 

restrooms because of the number of residents being evacuated and the anticipated 4-hour 

drive to Dallas.

The Sunrise vice president for sales and marketing and the vice president for 

operations contacted BusBank on September 21 to arrange transportation for the Brighton 

Gardens residents. BusBank first informed Sunrise that it did not have any motorcoach 

72 These inspections included 2,309,258 trucks and 71,464 buses. See <www.ai.fmcsa. dot.gov/ 

stateprofile/profile.asp>, November 27, 2006.

73 See <www.sunriseseniorliving.com>, September 13, 2006.

74 Global Limo Inc. was not the passenger carrier provided by BusBank for the Hurricane Katrina 

contract.
Factual Information 34 Highway Accident Report

operators available to provide charter evacuation services because FEMA had contracted 

approximately 275 motorcoaches for posthurricane operations. Shortly thereafter, 

BusBank informed Sunrise that it found two motorcoaches to transport Brighton Gardens 

residents from Bellaire to Dallas. According to Sunrise, it was not given the name of the 

motorcoach operator. The accident motorcoach, which carried 37 residents, was 

staffed with 3 nurses and 3 nurses’ aides (and 1 parent of a nurse). Global’s second 

motorcoach completed the trip as outlined in the contract and trip itinerary; it transported 

16 ambulatory passengers and arrived at its destination on the morning of September 23.

Brighton Gardens is a licensed facility and did have a preparedness plan. 75 At the 

time of the Hurricane Rita evacuation,76 the Sunrise Senior Living plan, titled Preparing 

the Community for a Complete Evacuation, stated, “If the evacuation is decided: 

Transportation arrangements will be confirmed.” There were no other written procedures 

for arranging transportation for residents.

Bus Brokers

A bus broker is an entity or business that arranges bus or motorcoach 

transportation between a client and a passenger motor carrier for a fee. Bus brokers are not 

required to obtain a DOT registration or operating authority from the FMCSA. An 

FMCSA official testified at the public hearing that the agency does not have the authority 

to regulate brokers for motor carriers of passengers. In addition, on September 15, 2006, 

the FMCSA informed the Safety Board that 49 United States Code 13506(a)(14) exempts 

the Secretary of Transportation from jurisdiction over brokers for motor carriers of 

passengers. According to the FMCSA, the statute does give the DOT

authority to require brokers for motor carriers of passengers to maintain a bond or 

insurance as needed to protect passengers and carriers dealing with such brokers. 

The DOT, like the ICC before it, has not imposed an insurance requirement 

because, without the ability to register these brokers, the agency has no way to 

identify passenger brokers that are operating and monitor their compliance with 

an insurance requirement.

75 “Under current Texas law, only licensed facilities are required to maintain a written emergency 

preparedness and response plan; however, the law does not address the quality or currentness of a licensed 

facility’s plan. Unlicensed facilities are not required by law to maintain an evacuation plan.” State of Texas, 

Governor’s Task Force on Evacuation Transportation and Logistics (Austin, TX: Office of the Governor, 

February 14, 2006) 5.

76 Sunrise followed its written disaster plan in making evacuation arrangements. A section on 

“Hurricane Preparedness” included guidance covering such issues as keeping medical records and 

identification with evacuees; maintaining adequate supplies of food, medication, and other medical 

necessities; and securing the evacuated property.
Factual Information 35 Highway Accident Report

Global Charter Services, Ltd,77 doing business as The BusBank,78 is a Delaware 

corporation headquartered in Chicago, Illinois. BusBank was one of the vendors used by 

FEMA during the Hurricane Katrina evacuations. The BusBank website describes the 

corporation as

transportation and event specialists with local knowledge of bus availability, bus 

quality, the best routes, and seasonal events that impact bus transportation in 

hundreds of markets—thousands of cities—across North America. . . . Working 

with independent operators rather than owning buses, we maintain the flexibility 

to create customized group transportation solutions that fit the specific needs of 

the customer and situation.

BusBank maintains a registry of motorcoach companies and contacts them to 

arrange charters when needed. When a company agrees to the charter contract, the 

operator is given the itinerary and completes the trip. The group requesting the charter 

pays BusBank, which then pays the motorcoach company for its transportation services.

According to BusBank, the agreement requires that the motorcoach operator’s 

drivers be properly licensed. The carrier must comply with all applicable Federal, State, 

and local laws and regulations. Global did not have a formal contract with BusBank; its 

registration information was taken via telephone 1 year before the accident, and it had 

completed one prior charter for BusBank.

Oxygen Cylinders

The director of risk management for Sunrise stated in a Safety Board interview 

that Brighton Gardens employees placed medical oxygen79 cylinders both inside the 

passenger compartment and inside the luggage bay during passenger loading of the 

motorcoach. Initially, two cylinders were hooked up to nasal canulas80 and used to provide 

medical oxygen to two passengers inside the motorcoach. Fifteen cylinders, contained in 

metal racks, were placed in the luggage bay in the lower portion of the coach, along with 

passenger wheelchairs. During the trip, the oxygen within the cylinders in the passenger 

compartment was depleted, and the nursing staff requested that the driver pull over to 

retrieve additional cylinders from the luggage bay.

77 Global Limo Inc., the operator of the accident motorcoach, and Global Charter Services, Ltd, are two 

distinct and separate commercial entities.

78 See <www.busbank.com>, December 1, 2006.

79 Oxygen is an atmospheric gas. It is transported as a compressed or liquefied gas; it is not flammable 

but supports and enhances combustion. An oxygen-enriched atmosphere lowers the ignition temperatures of 

certain combustible materials and increases the intensity of a fire. Oxygen is also reactive with combustible 

materials and can cause a fire. Title 49 CFR Subchapter C 172.101 classifies oxygen as a nonflammable 

compressed gas, and 173.301(a) requires oxygen to be shipped in DOT specification cylinders.

80 A canula is a tube inserted into the nasal cavity to administer medical oxygen.
Factual Information 36 Highway Accident Report

During the Safety Board’s postaccident inspection, 18 cylinders,81 or parts thereof, 

were found in the cargo and passenger areas of the motorcoach; 15 cylinders were 

aluminum, and 3 were steel. Seven cylinders found in the luggage bay had limited fire 

damage. All 11 cylinders found inside the passenger compartment showed fire damage; 5 

were extensively damaged and had been found near the rear of the motorcoach. Of these 

five, the pressure-relief plated brass medical post valves on three aluminum cylinders 

were intact; two of these cylinders had evidence of melting, and one had fractured and 

burst just below the cylinder neck.82

According to the manufacturer of one of these cylinders, aluminum melts at 

1,020o–1,206o F and loses its strength at temperatures well below this range. A fully 

pressurized aluminum cylinder would maintain its integrity for only minutes at 

temperatures of about 600o F. These cylinders are designed to hold large quantities of gas 

by compressing it into a small volume, which results in high levels of pressure. When a 

cylinder fails, the rapid expansion of the compressed gas creates a pressure surge that 

radiates from the container and can carry along portions of the cylinder as projectiles. The 

Safety Board examined the three aluminum cylinders to determine how the structural 

failure occurred.

According to the manufacturer of several plated brass valves found on the accident 

motorcoach, the typical pressure relief device installed on this type of valve includes a burst 

disk83 set to actuate at 3,025–3,360 pounds per square inch gage (psig). These pressure relief 

devices are designed to open to relieve pressure within the cylinder before an exposure to 

high temperatures can cause the cylinder to fail.84 Examination of the three valves at the 

Safety Board’s laboratory revealed that one burst disk had actuated as designed, and two had 

not.85 One of the two that had not actuated was on the cylinder that had fractured and burst. 

The disks within these cylinders were examined, and no defects were found.

The Safety Board studied the effect of heating aluminum cylinders containing 

various quantities of oxygen, from fully charged at 2,015 psig to minimally charged at 

500 psig. The study revealed that the pressure-relief device on a fully charged cylinder 

81 The director of risk management was unable to explain why an additional cylinder was found in the 

motorcoach postfire.

82 Two other melted cylinders were found without the valves attached. One had holes melted through on 

the top head, and the other was only a base with attached resolidified aluminum.

83 A burst disk is a pressure-actuated device used to prevent the pressure in a normally charged cylinder 

from rising above a predetermined maximum, thereby preventing rupture of the cylinder when subjected to 

high temperatures.

84 Fire tests performed for the Compressed Gas Association (CGA) to establish standards for these 

pressure relief devices proved that they operated as designed when the cylinders were fully charged with 

gas. In accordance with 49 CFR Subchapter C and the CGA S-1.1 standard, these are the minimum 

requirements for pressure relief devices considered to be appropriate for use on cylinders with capacities of 

1,000 pounds of water or less; 49 CFR 173.301(f) requires that pressure relief devices be sized, selected, and 

tested in accordance with the CGA S1.1 standard and that they be capable of preventing rupture of a 

normally filled cylinder when subjected to a fire test conducted in accordance with the CGA C-14 standard.

85 In all, the plated brass medical post valves were still installed on 16 of the 18 recovered cylinders. 

Each cylinder was examined to determine whether the pressure relief device had actuated as designed.
Factual Information 37 Highway Accident Report

actuates, relieving its internal pressure before failure, at temperatures of 260o–315o F. 

However, it was also determined that the exposure of an aluminum cylinder with less than 

78 percent of its original quantity of gas (about 1,570 psig at room temperature) to 

temperatures exceeding 400o F reduces the strength of the aluminum to a point where the 

cylinder structurally fails before the pressure within the cylinder is great enough to 

activate the burst disk. It was also found that as the quantity of gas in the cylinder 

decreases, the temperature required to increase the internal pressure above the rupture 

pressure of the burst disk increases.

Federal HM regulations in 49 CFR Subchapter C 171.8 define materials of trade as 

those materials carried on a motor vehicle to protect the health and safety of the motor 

vehicle operator or passengers; section 173.6 states that when materials of trade (such as 

the medical oxygen cylinders) are transported by a motor vehicle, they are not subject to 

DOT shipping requirements, with certain provisions. On September 26, 2005, 3 days after 

the accident, the Pipeline and Hazardous Materials Safety Administration (PHMSA) 

issued guidance for the safe transportation of medical oxygen for personal use on buses 

and trains. This guidance was updated and rereleased on June 30, 2006.86 It suggests, in 

part, that the number of cylinders to be transported in a vehicle be limited to the extent 

practicable and, except in emergency situations, that bus or train operators consider 

limiting the number of passengers who require medical oxygen. The guidance specifies 

that each cylinder be equipped with a valve protection cap and be secured away from 

sources of heat or potential sparks. PHMSA also suggests that the total weight of oxygen 

cylinders permitted in a bus cargo compartment not exceed 99 pounds, though a carrier 

may elect to transport up to 440 pounds in the cargo compartment if the oxygen is required 

for passenger health or safety.

When a new cylinder design or technology is developed, manufacturers apply to the 

DOT for a special permit87 to use the new technology. Prior to 1981, aluminum cylinders 

were manufactured, tested, inspected, and placed on the market as exempt from DOT 

regulations, which applied to steel cylinders. In 1981, aluminum exemption cylinders 

became subject to 49 CFR 178.46, specification 3AL seamless aluminum cylinders.

Meteorological Information

The Lancaster Airport in Lancaster, Texas, about 4 miles west of the accident site, 

was the closest official weather-observing system. At 6:03 a.m. on September 23, 2005, it 

reported visibility unrestricted at 10 statute miles, a temperature of 72o F, and scattered 

clouds above 9,500 feet.

86 U.S. Department of Transportation, Pipeline and Hazardous Materials Safety Administration, 

Guidance for the Safe Transportation of Medical Oxygen for Personal Use on Buses and Trains 

(Washington, DC: PHMSA, 2006).

87 The Hazardous Materials Safety and Security Reauthorization Act of 2005 (Public Law 109-59), 

Stat. 1144 (August 10, 2005), amended the Federal HM transportation law by changing the term 

“exemption” to “special permit.”
Factual Information 38 Highway Accident Report

Toxicological Information

Toxicological specimens were not collected from the accident motorcoach 

driver. According to 49 CFR 382.303, the employer of a driver of a commercial motor 

vehicle operated on a public road in commerce is required to conduct alcohol and 

controlled substance testing on that driver if the vehicle is involved in a fatal accident.88

Global did not test the driver postaccident for alcohol or illicit drugs. When interviewed 

by the Safety Board, the Dallas County Sheriff’s officer who responded to the fire stated 

that he lacked reasonable suspicion of intoxication to require the driver to submit to 

toxicological testing. 89

Other Information

Commercial Vehicle Inspections

According to Global’s owner, the accident motorcoach underwent a commercial 

vehicle inspection for the State of Texas on June 9, 2005, at Valley Volvo in Pharr, Texas. 

In Texas, the inspection of motor vehicles, including motorcoaches, is conducted in Stateapproved privately owned and operated garages, inspection-only facilities, and vehicle 

repair facilities,90 which are designated by the TxDPS under the Texas Vehicle Inspection 

Act.91 Under 49 CFR 396.17, the FMCSA requires that “every commercial vehicle shall 

be inspected as required . . . the inspection shall include, at a minimum, the parts and 

accessories set forth in appendix G of subchapter B.”92

88 Title 49 CFR 390.5 defines an accident as an occurrence involving a commercial motor vehicle 

operating on a highway in interstate or intrastate commerce that results in: “(i) a fatality; (ii) bodily injury to 

a person who, as a result of the injury, immediately receives medical treatment away from the scene of the 

accident; or (iii) one or more motor vehicles incurring disabling damage as a result of the accident, requiring 

the motor vehicle(s) to be transported away from the scene by a tow truck or other motor vehicle.”

89 Texas Transportation Code 724.012(b) states that: “[a] peace officer shall require the taking of a 

specimen of the person’s breath or blood if: (1) the officer arrests the person for an offense under Chapter 49, 

Penal Code, involving the operation of a motor vehicle or a watercraft; (2) the person was the operator of a 

motor vehicle or a watercraft involved in an accident that the officer reasonably believes occurred as a result 

of the offense; (3) at the time of the arrest the officer reasonably believes that a person has died or will die as 

a direct result of the accident; and (4) the person refuses the officer’s request to submit to the taking of a 

specimen voluntarily.”

90 According to 49 CFR 396.23, a vehicle meets Federal requirements if inspected under a mandatory 

State inspection program, such as the State of Texas vehicle inspection program.

91 All inspection-authorized facilities are required to operate according to the Rules and Regulations 

Manual for the Operation of Official Vehicle Inspection Stations, which is issued and maintained by the 

TxDPS. Texas Transportation Code, “Compulsory Inspection of Vehicles,” chapter 548.

92 As specified in 49 CFR 396.17(f), vehicles passing roadside or periodic inspections performed under 

the auspices of any State government or equivalent jurisdiction or the FMCSA, and meeting the minimum 

standards contained in appendix G of this subchapter, are considered to have met the requirements of an 

annual inspection for a period of 12 months commencing from the last day of the month in which the 

inspection was performed, except as provided in 396.23(b)(1).
Factual Information 39 Highway Accident Report

Title 49 CFR Parts 393 and 396 set forth FMCSR guidelines pertaining to 

commercial vehicle tires, wheels, and lubrication. (See appendix D.) In appendix G of 

subchapter B,93 the FMCSRs list the minimum periodic inspection standards for 

commercial motor vehicles. According to the standards, “a vehicle does not pass an 

inspection if it has several defects or deficiencies for tires.” Wheel bearings or wheel seal 

leaks are not specifically addressed.

Title 49 CFR 396.3 specifies that every motor carrier shall systemically inspect, 

repair, and maintain, or cause to be systematically inspected, repaired, and maintained, all 

motor vehicles subject to its control.94 Parts and accessories are to be kept in safe and 

proper operating condition at all times, including “those specified in Part 393 of this 

subchapter and any additional parts and accessories” that may affect safety of operation, 

“including but not limited to, frame and frame assemblies, suspension systems, axles and 

attaching parts, wheels and rims, and steering systems.” Section 396.5 states: “Every 

motor carrier shall ensure that each motor vehicle subject to its control is: (a) properly 

lubricated; and (b) free of oil and grease leaks.” Section 396.7 states:

(a) General–A motor vehicle shall not be operated in such a condition as to likely 

cause an accident or a breakdown of the vehicle. (b) Exemption–Any motor 

vehicle discovered to be in an unsafe condition while being operated on the 

highway may be continued in operation only to the nearest place where repairs 

can be safely affected. Such operation shall be conducted only if it is less 

hazardous to the public than to permit the vehicle to remain on the highway.

Title 49 CFR 393.205 addresses parts and accessories for the safe operation of wheels, 

stating: “(a) Wheels and rims shall not be cracked or broken. (b) Stud or bolt holes on the 

wheels shall not be elongated (out of round). (c) Nuts or bolts shall not be missing or loose.”

Motorcoach Tire Fire Testing

To better understand the events surrounding the outbreak of a tire fire and the 

characteristics that account for the severity of this type of fire, the Safety Board conducted 

three tire fire tests95 by

• Running a tire at various levels of inflation below the operating pressure 

specified by the manufacturer,

93 The vehicle portion of the FHWA’s North American Uniform Driver Vehicle Inspection Procedure

requirements, the CVSA’s North American Commercial Vehicle Critical Safety Inspection Items and Out-ofService Criteria, and the FMCSRs’ appendix G of subchapter B, Minimum Periodic Inspection Standards, 

are similar documents and follow the same inspection procedures. Appendix G requires that all items to be 

inspected be in proper adjustment, not be defective, and function properly prior to the vehicle being placed 

in service.

94 FMCSA interpretation guidance assigns responsibility for inspecting and maintaining leased 

vehicles and for maintaining records to the motor carrier that has the vehicle subject to its control for 30 

consecutive days or more, and the motor carrier is solely responsible for ensuring that the vehicles under its 

control are in safe operating condition and that defects have been corrected. See <www.fmcsa.dot.gov>, 

November 22, 2006.

95 Participants and witnesses to the tests included staff from the Safety Board, the FMCSA, Greyhound 

Bus Lines, MCI, Lancer Insurance, and Bridgestone.
Factual Information 40 Highway Accident Report

• Inducing failure of a wheel bearing from lack of lubrication, and

• Inducing failure of a wheel bearing by removing the bearing rollers.

A 2003 MCI G4500 model motorcoach, fitted with a nonsteering tag axle and 

Firestone FS400 tires, was used in the tests, which were run on a 7.7-mile circumference 

oval track at the Firestone proving grounds, Fort Stockton, Texas, on August 26–27, 2006.

Test results indicated that

• The underinflated tire test temperatures did not increase enough to ignite the 

tire.

• The dry wheel bearing caused a tire fire after about 1.5 laps around the track.

• The failed outer bearing led to a fire, which was not permitted to continue and 

ignite the tire.

A portable 20-pound dry chemical ABC fire extinguisher was used in an initial 

attempt to extinguish the two fires. In the second test, the fire restarted and was 

temporarily extinguished with a hose line and water; the fire restarted two more times and 

was finally extinguished with the repeated use of a firefighting hose line and water 

application. The third test resulted in a fire between the brake shoe and brake drum 

components; a chemical extinguisher was used to knock down the fire, which reignited. 

The fire was put out again with the chemical extinguisher and did not reignite.

Federal Railroad Administration Research

At the Safety Board public hearing, a Federal Railroad Administration (FRA) 

specialist for passenger train system safety and emergency preparedness testified that, in 

1999, the FRA concluded a series of rulemakings on requirements to prevent fire ignition, 

minimize fire spread and smoke emissions, and maximize the time available for passenger 

and crew egress, as codified in 49 CFR Part 238 and appendix B. Most combustible 

materials used in passenger railcars and locomotive cabs, organized by categories and 

functions, are required to be tested and meet certain flammability and smoke emission 

criteria. In addition, a structural floor fire endurance test is required.

The FRA also submitted the following written testimony:

Currently, under the FRA sponsorship, the Volpe (National Transportation 

Systems) Center is conducting emergency evacuation and fire safety research to 

assist in determining whether the amount of time available to evacuate a 

passenger railcar is sufficient, given the amount of time occupants actually need to 

evacuate safely using the available emergency egress features in a car. The Volpe 

Center’s research approach is two-pronged. Fire safety-related research findings 

can assist in determining the amount of available time for evacuation before 

conditions onboard become untenable due to smoke and fire, and emergency 

evacuation simulations can be used to predict the amount of time it takes to 

evacuate cars under various circumstances and in different operating 

environments. Findings from this research may be used to supplement existing 

emergency egress standards.
Factual Information 41 Highway Accident Report

Appendix E provides additional excerpts from the FRA public hearing submission 

on passenger railcar fire and safety regulation history.

Motorcoach Fires and Research Studies in Germany and Finland

On behalf of the German Ministry of Transport, the consulting group DEKRA96

studied 55 motorcoach fires from 1999–2004.97 The study included review of existing 

regulations for fire testing of materials used in motorcoaches and testing of motorcoach 

components. DEKRA reported that information on fire testing could be adopted from the 

railroad sector for use in testing motorcoach construction materials. The study emphasized 

the importance of early detection and recommended a system of thermodetectors, 

automatic fire suppression systems, and optical smoke detectors within the passenger 

compartment.

On February 13, 1999, the Accident Investigation Board of Finland began its 

investigation of a fire in a coach near Tampere, Finland. In autumn 2000, the Accident 

Investigation Board initiated a bus fire project to obtain bus fire statistics and determine 

the reasons for recurring fires.98 The study found that a fire that begins outside the 

passenger compartment may spread into the passenger compartment very quickly and, in 

the worst case, prevent passenger egress. “Normally the fire moves into the passenger 

compartment from outside after the flames have broken either the rear window or the side 

window next to the engine.” The report found no difficulties experienced during the 

evacuations investigated but acknowledged that “the situation could change significantly 

if, for example, there are disabled passengers in the vehicle.” Another conclusion, based 

on the fire incidents reviewed, was that “if the driver has not extinguished the fire, or has 

not prevented it from spreading, and the firefighters’ arrival time is more than 10 minutes, 

then the fire will already have moved to the passenger compartment.”

The study found that fixed fire-extinguishing/suppression systems are rare in 

Finland; according to bus company owners and bus body manufacturers, the system’s 

price is considered to be the main obstacle to its widespread use. The study determined 

that the extra cost of the system installed in a new bus added about 1.0 percent to the 

purchase price. One report recommendation was that all new buses be equipped with an 

automatic or semiautomatic fixed fire-extinguisher system, and another called for bus 

company owners to provide every driver with first-hand fire-extinguishing training and at 

regular intervals arrange practice in the use of fire extinguishers and in passenger 

evacuations.99

96 See <www.dekra.com/english/auto.htm.>, November 14, 2006.

97 Markus Egelhaaf and F. Alexander Berg, Motor Coach Fires: Analysis and Suggestions for Safety 

Enhancement, Paper Number 05-0094 (Berlin, Germany: Ministry of Transport, 2005).

98 Accident Investigation Board, Bus Fires in Finland During 2000, translation from shortened Finnish 

version (Helsinki, Finland: 2001).

99 Recommendation numbers D1/00Y/S1 and D1/00Y/S4, respectively.
Factual Information 42 Highway Accident Report

DOT Evacuation Research Studies

Intercity Buses. On December 1, 1976, the FHWA contracted with the University 

of Oklahoma to study the evacuation of intercity buses.100 The study was the third in a 

series to “document the problems with evacuation or escape from automobiles and buses 

after a crash.”101 Part of the study included a literature review of accident reports, 

published materials, and research reports. One report recommendation was that 

emergency exit time standards be developed under different collision configurations and 

possibly be patterned after existing Federal Aviation Administration (FAA) aircraft exit 

standards.

The evacuation study analyzed three evacuation simulations with a full 

complement of passengers102 and noted “that there is a great disparity in the total time [in] 

which each window exit was used for escape and the number of persons escaping.” In 

comparing escape times to vehicle positioning and lighting conditions, the study explained 

that “the overall escape times are not comparable because the use of the front door as an 

exit caused a significant reduction in escape time, particularly for removal of the [injured] 

passengers.” The study concluded that the

maximum time to permit for a bus evacuation cannot be fully determined with the 

data currently available. However, the standard used by the FAA for aircraft 

evacuation should be carefully considered, i.e., 90 seconds time [Federal Aviation 

Administration Regulations 25 CFR Part 803] with one-half the available exits 

being used.

Also included in the report was information about comments submitted to the 

DOT when Federal Motor Vehicle Safety Standard (FMVSS) 217 was proceeding through 

the rulemaking phases prior to becoming effective in 1973. One problem noted was the 

potential for injury to motorcoach passengers when the escape exit used was 7–8 feet 

above ground level. The Oklahoma University Research Institute suggested the following 

changes to the proposed FMVSS 217:

The maximum allowable force of 60 pounds for opening an emergency exit 

should be reviewed and push-out windows serving as emergency exits should be 

required to include a method for keeping them open after they have been initially 

opened. The reason for the suggestion was that windows falling back on 

passengers egressing impede egress and can also produce injuries.

100 U.S. Department of Transportation, Federal Highway Administration, Evacuation of Intercity Buses, 

Oklahoma University Research Institute (Washington, DC: FHWA, 1977).

101 The first two studies focused on all vehicles, including passenger cars and buses. (a) U.S. Department 

of Transportation, Federal Highway Administration, Escape Worthiness of Vehicles and Occupant Survival, 

First Part: Research Program, Oklahoma University Research Institute, FH-11-7303 (Washington, DC: 

FHWA, 1970). (b) Escape Worthiness of Vehicles for Occupancy Survivals and Crashes, Oklahoma 

University Research Institute, FH-11-7512 (Washington, DC: FHWA, 1972).

102 The three conditions were: the motorcoach in an upright condition in darkness with and without the 

front door accessible, the motorcoach overturned onto its right side in darkness with the front loading door 

blocked, and the motorcoach turned on its right side with on-board emergency illumination.
Factual Information 43 Highway Accident Report

Paratransit Buses and Vans. In 1984, the DOT published a report on the 

evacuation and rescue of elderly and disabled passengers from paratransit vans and 

buses.

103 According to the report:

To ensure the safety of passengers on paratransit vans and buses, efficient and safe 

methods of rescuing them are needed. Standard methods are not always useful for 

these patrons as a result of their physical and mental condition and their 

insufficient ability to manage self-evacuation.

The scope of the research program included the preparedness of emergency 

rescue personnel and transit operators. The report recognized that “if the vehicle catches 

fire, the passengers and the driver may have to rely on the immediate help of nearby 

motorists before professional rescue personnel arrive.” In discussing emergency exits, 

the report states that push-out windows severely limit use by the elderly and disabled 

because the “release forces can be high,” and the windows “are not easily releasable 

from the outside.”

Report data from 1984 indicate that 70 percent of all fires in intercity 

motorcoaches developed in the rear of the bus, particularly in the wheel well and engine 

compartment (accounting for 40 percent of fires); and that these fires, because of their 

locations, often grew before they were detected. The report also recognized that 

motorcoaches contain large amounts of materials capable of supporting combustion and 

producing smoke and flames.104

FMCSA Stakeholder Forums. In February–March 2003, the FMCSA held a 

series of five forums to gather stakeholder input regarding the agency’s research agenda 

and to educate stakeholders about the Office of Research and Technology and ongoing 

projects. More than 150 recommendations were made by stakeholders to the FMCSA, one 

of which pertained to vehicle-related research to “study the adequacy of motor coach 

evacuation plans for disabled and/or wheelchair dependent riders.”105 To date, no research 

or further information on this proposal has been published.

Emergency Evacuation of Civil Aircraft. In July 1977, the FAA published a 

report on emergency escape of handicapped air travelers,106 which included discussion of a 

Civil Aeromedical Institute investigation of potential problems related to the emergency 

evacuation of civil aircraft carrying persons with special needs. The study included an 

analysis of the movement of individual subjects in an aircraft cabin and the results of 

103 U.S. Department of Transportation, Evacuation and Rescue of Elderly and Disabled Passengers 

From Paratransit Vans and Buses, Report UMTA-MA-06-0152-84-3 (Washington, DC: 1984).

104 Such materials include wooden floors with rubberized coverings, foam insulation and upholstery, 

fiberglass-reinforced polyester resin body panels and components, and plastic-coated trim panels and wiring 

harnesses.

105 See<www.fmcsa.dot.gov/facts-research/research-technology/report/forum-report-digital-version-all.htm>,

July 20, 2006.

106 U.S. Department of Transportation, Federal Aviation Administration, Emergency Escape of 

Handicapped Air Travelers, Report FAA-AM-77-11 (Washington, DC: FAA, 1977).
Factual Information 44 Highway Accident Report

evacuation tests in which a portion of the test subjects either were disabled or had 

simulated disabilities. The report concluded:

Assisting handicapped passengers in an aircraft cabin is difficult because of space 

limitations generated by the seat configurations. Fixed armrests, restrictive seat 

pitch (distance between similar points on seats), and restrictive aisle widths made 

assistance difficult and interfered with movement.

The evacuation tests showed that 96 percent of ambulatory disabled persons 

reached the exit in 30 seconds or less, though only 37 percent of nonambulatory persons 

reached the exit in that time. These latter subjects would probably require assistance from 

other passengers or crew during a critical evacuation; this conclusion, according to the 

FAA, is in agreement with the results of previous evacuation demonstrations and analyses 

of accident data, which indicate that passenger movement at a rate of at least 1 foot per 

second is the minimum required for a successful evacuation.

Federal Motor Vehicle Safety Standards

The purpose of the DOT’s FMVSSs is to reduce the risk of a vehicle crash by 

specifying minimum performance levels for brakes, lights, and other components; and to 

reduce the risk of injury, should a crash occur, by specifying minimum requirements for 

vehicle performance as related to occupant protection, occupant restraints, roof and body 

joint strength, fuel system integrity, and child safety systems.

FMVSS 301, Fuel System Integrity, was issued to reduce the risk of fatalities and 

injuries due to fires from motor vehicle crashes. The standard applies to passenger cars, 

light trucks, and school buses with applicable fuel (boiling point above 32o F). It 

prescribes impact test requirements to strengthen and protect the vehicle’s fuel system and 

to reduce the likelihood of fuel-fed fires caused by fuel system breaches into the vehicle. 

FMVSS 301 does not apply to buses with a gross vehicle weight rating over 10,000 

pounds or to motorcoaches.

FMVSS 302, Flammability of Interior Materials, was issued to reduce the deaths 

and injuries to motor vehicle occupants caused by vehicle fires, especially those 

originating in the interior of the vehicle from sources such as matches and cigarettes. This 

standard specifies burn resistance requirements for materials used in the occupant 

compartments of motor vehicles. It applies to passenger cars, multipurpose passenger 

vehicles, trucks, and buses.

Emergency Evacuation of Persons With Special Needs

Federal, State, and local governments, as well as individual health care facilities, 

have plans for responding to emergencies such as hurricanes. At the Federal level, the 

National Response Plan (NRP)107 provides the framework for how the Federal government 

107 As established by Homeland Security Presidential Directive 5, the NRP is intended to provide a 

single comprehensive approach to domestic incident management to prevent, prepare for, respond to, and 

recover from terrorist attacks, major disasters, and other emergencies.
Factual Information 45 Highway Accident Report

will assist States and localities in managing domestic incidents. The National Disaster 

Medical System (NDMS),108 an NRP program, includes assistance to State and local 

governments specifically with evacuation of hospital residents. Neither the NRP nor the 

NDMS addresses the evacuation of residents in nursing homes or assisted living centers, 

rehabilitation facilities, or hospice care.

Nursing home residents fall within the broad category of populations that face 

particular challenges during emergencies. Nursing homes that participate in Medicare 

and Medicaid must comply with standards established by the HHS Centers for Medicare 

and Medicaid Services (CMS), which include requirements that they have plans to meet 

potential emergencies and disasters; the interpretive guidelines do not specifically refer to 

evacuation of residents. According to a July 2006 Government Accountability Office 

(GAO) report to Congress on evacuation of health facilities during disasters, CMS 

officials have established a working group to review hospital and nursing home 

requirements for emergency preparedness, including issues related to evacuation.109

At the Safety Board public hearing, participants discussed a range of issues 

concerning emergency preparedness for persons with special needs. The director of the 

emergency preparedness initiative for the National Organization on Disability, a witness at 

the hearing, defined persons with special needs as “people with disabilities, mobility 

impairments, sensory impairments, [or] cognitive or mental health impairments.” The 

senior director of the Florida Health Care Association Quality Credentialing Foundation 

explained at the public hearing that sheltering in place is often preferable to evacuating 

nursing home residents because of the risk of transporting the medically frail.

Other hearing participants also stressed the difficulty of obtaining appropriate 

evacuation transportation in an emergency. Once the decision to evacuate is made, 

numerous factors have to be considered, such as the medical, mobility, and mental 

conditions of each individual. These factors affect the optimum mode of transportation, 

which in some cases will be ambulance. During a large-scale evacuation, such as those 

typical of a hurricane response, hospitals and other facilities for acutely ill individuals are 

prioritized for the limited number of ambulance and similar transportation assets in the 

community. Included in the public hearing was discussion of how the lack of coordination 

among State emergency response agencies and the lack of interstate emergency mutual aid 

agreements could hamper the effectiveness of evacuating persons with special needs.

Texas Evacuation of Persons With Special Needs. When Hurricane Rita 

approached the Texas Gulf Coast, government and private entities began considering the 

evacuation of coastal areas. According to the Texas Building and Procurement 

108 The NDMS—a partnership of the U.S. Department of Homeland Security (DHS), U.S. Department 

of Defense, U.S. Department of Health and Human Services (HHS), and U.S. Department of Veterans 

Affairs—can be activated to assist in medical response and patient evacuations. Within the NDMS, the DOT 

is responsible for patient evacuation from mobilization centers (airfields) to Federal coordination centers 

and medical facilities.

109 Government Accountability Office, Disaster Preparedness Limitations in Federal Evacuation 

Assistance for Health Facilities Should be Addressed, GAO-06-826 (Washington, DC: GAO, 2006) 17. See 

<www.gao.gov/cgi-bin/getrpt?GAO-06-826>, September 26, 2006.
Factual Information 46 Highway Accident Report

Commission (TBPC), it was tasked during a September 19, 2005, State Operations Center 

meeting with procuring 1,100 buses and motorcoaches for the evacuation of persons in 

levels 1 through 3 of special needs assistance.110 The TBPC contacted the American Bus 

Association, the United Motorcoach Association, and the Texas Bus Association for 

assistance in fulfilling this procurement. The TBPC eventually contracted with 48 charter 

bus and motorcoach companies, which provided 307 charters; it had attempted to obtain 

handicap-accessible buses and motorcoaches, with the objective of having one-third of the 

vehicles be compliant with the Americans With Disabilities Act (ADA).111

When a government or private entity requested evacuation transportation assistance 

via the State of Texas Emergency Operations Center, the TBPC was contacted to dispatch 

motorcoaches from one of the three staging areas under TxDPS control. Some specialty 

buses and motorcoaches were available to accommodate passengers with special needs. The 

TBPC stated that it was able to meet all transportation requests made through the operations 

center during the emergency. Sunrise management stated that they were not aware of the 

State’s TBPC transportation assistance when they chartered through BusBank.

Since Hurricane Rita, the TBPC has entered into contingency contracts with 

carriers for 1,020 buses and motorcoaches.112 It has also awarded a contingency contract 

for bus transportation management services113 to Coach USA, LLC (CUSA).114 In the 

event of an emergency, CUSA is to provide logistical support, dispatch services, and an 

additional 80 motorcoaches. CUSA representatives will work from the State Emergency 

Operations Center 24 hours a day and provide support at staging areas. CUSA will have 

direct technical supervision over carriers during the evacuation process and is responsible 

for ensuring that buses and motorcoaches are appropriately equipped for the assigned 

mission, including having necessary ADA accommodations, sufficient fuel, functioning 

air conditioning, and on-board toilets and safety equipment.

Texas Task Force on Evacuation, Transportation, and Logistics. In October 

2005, the Governor of Texas appointed a 14-member task force to document lessons 

learned from the hurricane evacuation and to make recommendations for improving 

110 Texas categorizes special needs individuals under five levels of increasing assistance. Level 1: 

dependent on others for routine care, such as eating, walking, and toileting; level 2: disabilities such as 

hearing or vision impairment; level 3: assistance with medical care administration or dependent on 

equipment; level 4: living outside an institutional facility care setting but requiring extensive medical 

oversight, such as needing a ventilator or life support assistance; and level 5: needing the highest level of 

care and living in an institutional setting.

111 The TBPC said that it considered using school buses and municipal mass transit but determined that 

this was not feasible because of the long distances likely to be traveled during a major evacuation, as well as 

fueling considerations.

112 The State of Texas has identified the need for 1,100 motorcoach-type buses to evacuate its 

special needs populations. One-third of the contracted vehicles must be ADA compliant.

113 The motorcoach contracts require that contractors provide copies of their insurance and have a 

satisfactory FMCSA safety rating. The contractors may not have existing contingency contracts that would 

take precedence over the State of Texas contract.

114 CUSA, operating under the Coach USA brand name, is one of the Nation’s leading providers of 

motorcoach services.
Factual Information 47 Highway Accident Report

evacuation plans and execution. On February 14, 2006, the task force issued its final 

report,115 including information from public hearings held with stakeholders such as 

evacuees, local and State officials, charitable organizations, relief and hospital workers, 

medical personnel, and individuals with special needs and their caregivers.

The task force found that Texas does not clearly assign responsibility for 

identifying, transporting, and sheltering individuals with special needs. To address this 

problem, it recommended that the Governor “direct the development and implementation 

of a statewide special needs evacuation and shelter plan.” The task force noted that care 

should be taken to ensure that the plan includes citizens with special needs who do not live 

in an institutional environment and that officials should maintain a database of citizens 

with specials needs to ensure proper planning and execution of their evacuation. Officials 

should also document those facilities or residences where medical or handicap-accessible 

vehicles will be required during an evacuation.

The report indicated that some Texas facilities in which individuals with special 

needs reside do not have evacuation plans, and some that do have plans may not have 

ensured that they are adequate and up to date. The task force recommended that the 

Governor “direct all licensed and unlicensed special needs facilities to maintain 

evacuation plans that have been approved by the local jurisdiction and the Regional 

Unified Command” and update them annually. Governor Executive Order RP-57, issued 

on March 21, 2006,116 directed the implementation of the task force recommendations.

Federal Evaluation of Catastrophic Hurricane Evacuation Plan

After Hurricanes Katrina and Rita struck the Gulf Coast in 2005, Congress asked 

the DOT, in cooperation with the DHS, to “review and assess Federal and State evacuation 

plans . . . for catastrophic hurricanes and other catastrophic events impacting the Gulf 

Coast region.” The DOT issued its report to Congress on June 1, 2006.117 The report 

covered the evacuation of persons with special needs and the broader topic of the roles of 

Federal, State, and local governments in evacuations.

Based on its evaluation of State and local evacuation plans in each of the five Gulf 

Coast States (Alabama, Florida, Louisiana, Mississippi, and Texas), the DOT determined 

that “a significant majority of the evacuation plans were judged to be either marginally or 

partially effective regarding provisions for evacuating persons with various special 

needs.”118 In particular, the report noted that the plans do not have detailed information on 

precisely how to evacuate special needs populations or what additional resources are 

necessary to do so. Furthermore, the evacuation plans of residential facilities are often not 

coordinated with emergency management authorities and may not function adequately 

within the larger evacuation framework.

115 See <www.governor.state.tx.us/divisions/press/files/EvacuationTaskForceReport.pdf>, September 26, 2006.

116 See <www.governor.state.tx.us/divisions/press/exorders/rp57>, September 26, 2006.

117 See <www.fhwa.dot.gov/reports/hurricaneevacuation/rtc_chep_eval.pdf>, September 26, 2006.

118 U.S. Department of Transportation and U.S. Department of Homeland Security, Catastrophic 

Hurricane Evacuation Plan Evaluation: A Report to Congress (Washington, DC: DOT, 2006) 4-3.
Factual Information 48 Highway Accident Report

The DOT is developing a primer on evacuating populations of persons with special 

needs, which is intended to include essential information and technical assistance for State 

and local authorities, as well as for nongovernment entities charged with evacuating and 

sheltering people with special needs. A DOT inventory of more than 100,000 buses and 

motorcoaches nationwide is available for evacuation use. The DOT is working with the 

American Bus Association to index the capabilities of this inventory, including wheelchair 

compatibility, as well as the number and location of evacuation-ready vehicles and drivers.

The DOT report to Congress made several recommendations to improve mass 

evacuation planning and implementation, including joint development of regional mass 

evacuation plans by State and local authorities, with Federal agency input; involvement of 

nursing homes and other representatives of persons with special needs, as well as 

transportation agencies and operators, in the development of regional plans; and 

cooperation of State and local authorities in working with communities to develop systems 

to provide specialized transport or shelter during such events.119 (See appendix F for 

Federal special needs evacuation recommendations.)

GAO Report on Disaster Preparedness

On July 20, 2006, the GAO issued a report on the evacuation of hospitals and 

nursing homes during disasters,120 indicating that the 2005 Hurricane Katrina response 

propelled the study. The report focused on the deficiencies of the NRP and the NDMS 

with respect to evacuating nonhospital health facilities, such as nursing homes and longterm care facilities. One of the main problems the GAO identified was the difficulty of 

arranging evacuation transportation. Even when facilities had contracts with 

transportation providers, “competition for the same pool of vehicles created supply 

shortages.”121 Neither the NRP nor the NDMS was designed to help State and local 

governments evacuate healthcare facilities other than hospitals.

The report also noted two limitations of the NDMS that negatively affect its 

capability of assisting State and local governments with patient evacuation:

• NDMS evacuation efforts begin at a mobilization center, such as an airport, 

and do not provide for ambulances or other means of short-distance 

transportation necessary to move residents from healthcare facilities.

• The NDMS was not set up to handle the emergency transportation of persons 

with special needs who are not hospitalized, including nursing home 

residents.122

The GAO report called for executive action to clearly delineate how the Federal 

Government would assist State and local authorities in transporting hospital and nursing 

home occupants to mobilization centers (such as airports), where NDMS transportation 

119 Catastrophic Hurricane Evacuation Plan Evaluation: A Report To Congress, ES-11 and ES-12.

120 Disaster Preparedness: Limitations in Federal Evacuation Assistance for Health Facilities.

121 Disaster Preparedness: Limitations in Federal Evacuation Assistance for Health Facilities, 4–5.

122 Disaster Preparedness: Limitations in Federal Evacuation Assistance for Health Facilities, 15–17.
Factual Information 49 Highway Accident Report

responsibilities begin. It further recommended that the NDMS Federal partner agencies 

work together to determine how best to address the needs of nursing home residents 

during emergency evacuations. (See appendix F for Federal special needs evacuation 

recommendations.)

Lessons Learned From Federal Response to Hurricane Katrina

Following Hurricane Katrina, the Federal Government formally reviewed its 

response to this natural disaster. The Assistant to the President for Homeland Security and 

Counterterrorism submitted to the President The Federal Response to Hurricane Katrina: 

Lessons Learned report in late February 2006.123 The report included a section on the 

evacuation of populations of persons with special needs. Among FEMA’s critical 

challenges, as listed in the report, was providing buses and motorcoaches in coordination 

with the DOT, as provided in the NRP’s Emergency Support Function (ESF) #1, 

Transportation.124

The White House report made 125 recommendations for improving future Federal 

responses to disasters, 3 of which concern evacuation, as summarized below:

• Because of shortcomings in the Federal Government’s coordination of 

transportation during the Hurricane Katrina evacuations, the DOT should be 

designated as the primary Federal agency for conducting evacuations when 

State and local government resources are overwhelmed, and the DOT should 

conduct drills for undertaking this responsibility.

• The DHS should require State and local governments to “develop, implement, 

and exercise” plans for emergency evacuations.

• The DHS should also evaluate the evacuation plans of all States, as well as of 

the 75 largest urban areas in the United States.

See appendix F for Federal special needs evacuation recommendations.

123 The White House, The Federal Response to Hurricane Katrina: Lessons Learned (Washington, DC: 

2006). See <www.whitehouse.gov/reports/katrina-lessons-learned/>, September 26, 2006.

124 The Federal Response to Hurricane Katrina: Lessons Learned, 56.
50 Highway Accident Report

Analysis

The Safety Board considered the circumstances of the accident and several factors 

that may have been causal to the motorcoach fire, in addition to identifying safety issues 

related to vehicle fire reporting and inconsistent data within Federal accident databases, 

the FMCSA 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. Following a brief discussion 

of factors that were determined not to be causal to the accident, this analysis discusses 

causal factors and other safety issues.

Exclusions

The weather was clear and dry at the time of the accident. No defects in the 

highway or road design were found that would have caused or contributed to the 

accident. Although the hurricane evacuation was the reason for the trip, the Safety 

Board concludes that neither the weather conditions at the time nor the design and 

condition of the roadway caused or contributed to the accident. Following the accident, 

the motorcoach driver was not tested for alcohol because the Dallas County Sheriff’s 

officers detected no evidence of alcohol use or impairment. Although 49 CFR Part 382 

required Global to conduct postaccident testing for alcohol and illicit drugs, the 

company failed to do so; therefore, the Safety Board could not determine whether the 

driver was under the influence of alcohol or illicit drugs at the time of the accident. 

Because the motorcoach driver had been on duty for over 24 hours and had been driving 

consistently in heavy traffic for about 12 hours, it is highly unlikely that he had the time 

or the means by which to consume alcohol or illicit drugs. According to the FMCSA, 

Global is no longer in operation; nevertheless, the Safety Board is disappointed that the 

company failed to fulfill its responsibility for testing the driver for alcohol or illicit 

drugs following the accident.

Although the motorcoach driver stated that he had been diagnosed with type 2 

diabetes and was under a physician’s care in Mexico, neither he nor his employer 

provided the Safety Board with objective documentation regarding his condition. 

Therefore, the Safety Board concludes that a determination could not be made regarding 

the potential impact of the motorcoach driver’s medical condition on his response to the 

emergency.

When the fire occurred about 6:07 a.m. on September 23, 2005, the motorcoach 

driver had been on duty for just over 25 hours, and 21 hours of this time was spent driving. 

In addition, the fire occurred at a time of day when even well-rested individuals with 

daytime work hours (such as the accident driver) experience the lowest levels of alertness 
Analysis 51 Highway Accident Report

and performance. Scientific research has shown that fatigue is related to much more than 

just the time spent on a task,125 such as driving. Researchers have studied factors that 

affect fatigue, such as duration and quality of sleep,126 shift work, work schedules,127

circadian rhythms,128 and time of day.129 Cumulative sleep loss and circadian disruption, 

which the accident driver may have experienced during the Hurricane Rita evacuation 

emergency, can lead to a physiological state characterized by impaired performance and 

diminished alertness.130 Nonetheless, investigators determined that the wheel bearing fire 

occurred independent of the driver’s condition or actions. The Safety Board therefore 

concludes that the motorcoach driver was fatigued at the time of the tire fire, but his 

fatigue was not a causal factor in the accident.

When the driver arrived in Bellaire at 11:00 a.m. on September 22, from Pharr, 

Texas, he had been driving for 6 hours. He began driving again between 3:00 and 

3:30 p.m., when he left Bellaire, heading to Dallas. By 7:00 p.m., the motorcoach driver 

had reached the FMCSA-permitted hours-of-service threshold of 10 hours of driving. 

Thus, during the remainder of the time that he was driving, from 7:00 p.m. on September 22

until 6:00 a.m. on September 23, when the accident occurred, the driver exceeded the 

hours of service by 11 hours. Title 49 CFR 395.5 prohibits a passenger-carrying driver 

from driving more than 10 hours until being off duty for at least 8 consecutive hours; 

however, the regulations also state that a driver, in case of any emergency, may complete 

his or her run without being in violation of the provisions of the regulations, if such run 

reasonably could have been completed absent the emergency. The expected trip from 

Bellaire to Dallas was 4 hours, which would have concluded (absent the emergency 

situation of the hurricane evacuation) within the driver’s hours of service. Further, the 

Governor of Texas issued a proclamation on September 23, 2005, exempting all carriers 

and drivers involved in, and caught in, the hurricane evacuation from the hours-of-service 

regulations violations. Suspending the trip until the driver could obtain sufficient rest was 

125 M. H. Kryger, T. Roth, and W. C. Dement, eds., Principles and Practice of Sleep Medicine

(Philadelphia, PA: W. B. Saunders Company, 1994).

126 (a) L. C. Johnson and P. Naitoh, The Operational Consequences of Sleep Deprivation and Sleep 

Deficit, AGARD-AG-193 (London, U.K.: North Atlantic Treaty Organization, 1974). (b) M. R. Rosekind, P. 

H. Gander, L. J. Connel, and E. L. Co, Crew Factors in Flight Operations, X: Alertness Management in 

Flight Operations, NASA/FAA Technical Memorandum DOT/FAA/RD-93/18 (Washington, DC: National 

Aeronautics and Space Administration, 1994). (c) National Transportation Safety Board, Factors That Affect 

Fatigue in Heavy Truck Accidents, Safety Study NTSB/SS-95/01 and /02 (Washington, DC: NTSB, 1995).

127 (a) S. Folkard, T. H. Monk, and M. C. Lobban, “Towards a Predictive Test of Adjustment to 

Shiftwork,” Ergonomics, Vol. 21 (1979): 785–799. (b) G. R. Thomas, T. G. Raslear, and G. I. Kuehn, The 

Effects of Work Schedules on Train Handling Performance and Sleep of Locomotive Engineers: A Simulator 

Study, DOT/FRA/ORD-97-09 (Washington, DC: Federal Railroad Administration, 1997).

128 M. H. Kryger, T. Roth, and M. Carskadon, “Circadian Rhythms in Humans: An Overview,” 

Principles and Practice of Sleep Medicine (Philadelphia, PA: W. B. Saunders Company, 1994) 301–308.

129 C. D. Wylie, T. Schultz, J. C. Miller, and others, Commercial Motor Vehicle Driver Fatigue and 

Alertness Study: Project Report, FHWA-MC-97-002 (Washington, DC: Federal Highway Administration, 

1996).

130 M. R. Rosekind, R. C. Graeber, D. F. Dinges, and others, Crew Factors in Flight Operations, IX: 

Effects of Planned Cockpit Rest on Crew Performance and Alertness in Long-Haul Operations, NASA 

Technical Memorandum 108839, DOT/FAA/92/94 (Washington, DC: National Aeronautics and Space 

Administration, 1993).
Analysis 52 Highway Accident Report

not a viable option due to the impending hurricane and immense traffic delays and the lack 

of facilities for parking a motorcoach occupied by persons with special needs, including 

two who were reliant on a limited supply of medical oxygen.

The initial 911 calls provided an inaccurate location for the motorcoach accident, 

the Wilmer dispatch office had only one dispatcher on duty to handle all emergency calls, 

and the route to the accident was heavily congested with evacuation traffic. Nonetheless, 

several officers and deputies from the Wilmer Police Department and the Dallas County 

Sheriff’s Office were on scene within minutes. The first emergency call was received at 

6:07 a.m., and by 6:15 a.m., within 8 minutes, the fire had spread so extensively that the 

motorcoach was inaccessible for evacuation of the remaining passengers.

Despite the initial setback to the arrival of the Wilmer Fire Department, the 

emergency dispatch of personnel and equipment and the arrival of law enforcement 

officers on scene were not unduly delayed. Once the firefighters arrived about 6:24 a.m., 

they promptly began to extinguish the fire, thereby preventing its spread to surrounding 

areas and vehicles. Postaccident, the city of Wilmer installed an updated automated 

dispatch system to more effectively handle heavy call volumes and dispatching in 

emergencies. Although only a few minutes were available for the rescue of passengers 

from the motorcoach, the on-scene medical care and preparation for transport to hospitals 

were prompt and efficient. Therefore, the Safety Board concludes that appropriate 

resources were dispatched to the accident scene, that responders and medical personnel 

arrived as quickly as possible, considering the heavily congested roadways and the 

initially erroneous information about the accident location, and that the injured received 

medical care and were transported to local hospitals in a timely manner.

Accident Discussion

The Safety Board identified several factors indicating that the motorcoach caught 

on fire because of a lack of lubrication of the right-side tag axle wheel bearing, wheel 

bearing failure, and subsequent ignition of the tire. Among these factors were physical 

evidence from the scene and vehicle, along with interviews of Global’s owner and the 

accident motorcoach driver.

The Safety Board examined why the accident motorcoach driver, and the mechanic 

who provided roadside assistance on the day of the accident, did not recognize the first flat 

tire as an indication of an underlying mechanical issue with the vehicle. The motorcoach 

driver was initially alerted to the flat tire when he heard the tire blow out, and he took 

prudent action in pulling the motorcoach onto the interstate shoulder for the tire change. 

Because the flat tire occurred during the nighttime and in the middle of hurricane 

evacuation traffic congestion, the driver and the mechanic would not necessarily have 

been aware of the tire marks left by a locked wheel. When the driver assisted the mechanic 

by taking the flat tire and placing it into the spare tire compartment, the flat spot on the tire 

and wheel should have been noticeable under proper lighting conditions.
Analysis 53 Highway Accident Report

However, in the circumstances that existed at the time of the tire change, even a 

careful driver may not have made the connection that the flat wheel rim was caused by a 

locked wheel dragging—and not by pulling off onto the shoulder with an already flattened 

tire that was exposed to contact between the rim and the road surface. The Safety Board 

does not believe that a motorcoach driver, when involved in the same evacuation situation 

with similar environmental conditions as were present at the time of the tire change, would 

necessarily suspect a potentially hazardous mechanical malfunction beyond a flat tire. 

Moreover, given the 5 minutes during nighttime hours in which the mechanic changed the 

tire, as well as the urgency to move the motorcoach, which was partially blocking 

hurricane evacuation lanes, the mechanic did not have the opportunity to assess what 

conditions may have led to the flat tire.

The Safety Board also considered whether construction of the motorcoach 

contributed to the rapid propagation of the fire and whether motorcoach emergency egress 

systems afforded safe evacuation to occupants.

Heat Source and Fire Ignition

The Navarro County Sheriff’s Department received a call for the motorcoach flat 

tire at 3:22 a.m. on September 23, 2005, near Rice, Texas. Postaccident examination of the 

motorcoach and roadway revealed that the right-side tag axle (3R) tire locked just south of 

FM 1126, leaving 6,800 feet of tire marks on the I-45 road surface. When the 3R tire 

locked, the portion of the tire contacting the pavement was being pulled—not rolling—

which caused the blown tire. Once the tire flattened, the weight of the vehicle caused 

contact between the pavement and wheel rim, wearing a flat spot on the rim. The driver 

heard the right-rear tire blow out, and he pulled off the roadway.

The mechanic who responded to the call for roadside assistance finished the tire 

change by about 4:30 a.m.; however, he did not notice the locked wheel and replaced the 

blown tire with the motorcoach spare tire. Once the tire was changed, the Rice police 

officer advised the driver and the mechanic to drive their vehicles to the next exit to 

complete payment. Afterward, the motorcoach driver reentered I-45 and continued driving 

north.131 Less than 1 hour later, a motorist observed that the right-rear wheel was glowing 

orange-red and stopped the motorcoach driver to inform him of the problem. The driver 

moved the motorcoach across the lanes of travel, pulled off onto the shoulder, exited the 

vehicle, and immediately observed flames in the right wheel well. The Safety Board 

determined that the accident sequence of events began with a lack of lubrication in the 

right-side tag axle wheel bearings, which ultimately led to the tire fire.

A wheel bearing unit can fail when it lacks lubrication, which prevents the bearing 

rollers from rotating freely and leads to friction, which in turn begins to generate heat. The 

131 When wheel bearings seize and lock a wheel, it is possible that after a short period of cooling (such 

as might have taken place while waiting for the mechanic) the bearing rollers will reposition, allowing the 

hub and wheel to rotate again. The 3R wheel may also have rolled again due to the rollers being jarred when 

the motorcoach was placed on jacks, thereby allowing the applied spring brake to reposition both the 3R 

wheel and the rollers enough to allow the vehicle to move forward. Once the motorcoach reentered I-45 

north, the temperature in the 3R wheel components, including the hub assembly, began to rise again.
Analysis 54 Highway Accident Report

heat increases metal temperatures, causing deformation of the bearing rollers. The wheel 

bearings on the accident motorcoach were subjected to increased temperatures as they 

continued to support the weight (load) of the vehicle. As the roller metal began to degrade, 

the rollers started to flatten, disintegrate, and break down metallurgically. To deform and 

flatten, the rollers had to be subjected to temperatures of at least 1,000o F. The flattening of 

the rollers allowed them to be expelled from the bearing cages; the rollers then began to 

slide around within the bearing cup, and the bearing components lost concentricity around 

the axle spindle.

Because the flattened rollers no longer supported the weight of the motorcoach and 

no longer maintained evenly spaced wheel assembly parts, they continued to degrade and 

caused the wheel, hub, and rotor assembly to shift out of position. The outer edge of the 

brake rotor made contact with the underside of the disc brake carrier and caliper bridge. 

Heat and deformation caused some of the rollers to fuse, preventing the rotation of the 

wheel and hub and changing the orientation of the brake rotor and hub assembly, which 

caused contact with the foundation brakes. One witness at the Safety Board public 

hearing, the senior director of the North American brake business unit for ArvinMeritor, 

explained that as the wheel bearings continued to deform and increase friction within the 

wheel, the out-of-position brake rotor and hub assembly caused contact between the brake 

parts. With the rotor, carrier, and caliper bridge now in contact, the rotor began to grind 

against the stationary disc brake carrier and caliper bridge. This contact then increased the 

friction, which caused an increase in metal component temperatures and a rise in air 

temperatures within the wheel well surrounding the rubber tire. Friction from the grinding 

transferred heat to the wheel hub, which became visible as the bright red glow seen by the 

witness who stopped the motorcoach and warned the driver. This friction, coupled with 

the frictional forces generated by the turning rotor contacting the brake shoes, was enough 

to lock and prevent turning (rolling) of the 3R wheel (also referred to as “seizing”) at 

highway speeds.132

At some time in this sequence, the aluminum hubcap melted off the hub end; this 

event would have occurred when the hubcap reached an approximate temperature of 

1,150o F, at which point some of the hot and deformed rollers from the outer bearing cup 

were expelled from the hub and landed on the pavement.133 As noted by the ArvinMeritor 

representative, when the motorcoach came to rest, the now deflated tire came in contact 

with an area that “clearly had metal temperature in excess of the temperature required to 

ignite the rubber tire” (greater than 800o F). Safety Board tire fire testing conducted in 

August 2006 produced similar results when a motorcoach was run on a test track with 

wheel bearings lacking lubrication. The bearings failed, and the brake components 

overheated and subsequently came in contact with a blown tire, causing it to ignite.

Thus, the Safety Board postaccident investigation showed that the right-side tag 

axle (3R) wheel hub assembly was the cause of the motorcoach fire. The Safety Board 

concludes that the accident motorcoach was mechanically unsafe because the right-side 

132 In effect, this action binds the wheel to the axle.

133 These rollers were found by Safety Board investigators on the pavement in the area of the grass fire, 

approximately 3.2 miles south of the accident location.
Analysis 55 Highway Accident Report

tag axle wheel bearing assembly lacked sufficient lubrication, which resulted in high 

frictional forces and high temperatures, causing the wheel bearings to fail and igniting 

the tire.

Motorcoach and Bus Fire Data

After this accident, the Safety Board was given access to insurance data from two 

companies and to the analyses performed by two large self-insured passenger-carrying 

motor carriers. Although these sources provided considerable data on motorcoach and bus 

fires, the databases do not cover the entire spectrum of bus fires. Local fire departments 

report vehicle fires to the States, and the States then report the data to the NFPA. However, 

the reporting requirements vary; and the definition of buses is broad, thus making it 

difficult even to search the NFPA data for information on motorcoach fires. Further, police 

agencies use the ANSI Manual on Classification of Motor Vehicle Traffic Accidents, 

which defines traffic accidents as involving motor vehicles in transport on a trafficway.134

Motorcoach or bus fires that are not caused by vehicle collisions or do not originate while 

the vehicle is on the roadway are often not included in these databases. As a result, major 

highway safety accident data files, such as NHTSA’s FARS and GES, which collect data 

from police reports, do not capture the entire motorcoach or bus fire problem.

Other inconsistencies in fire reporting data are apparent as well. For example, the 

GES database listed only two motorcoach accidents from 1995–2003 that involved fires. 

The FARS data for 1994–2004 revealed 24 fatal motorcoach fires, a finding inconsistent 

with the GES data. Further, the FMCSA’s MCMIS data from 1995–2005 reported 265 

motorcoach fires, of which 4 involved fatalities.

The MCMIS accident file was developed to allow research on motor carrier safety 

problems and to potentially provide a census of all trucks and buses involved in traffic 

accidents. In 2002, the Safety Board noted the FMCSA’s acknowledgement that not all 

accidents were reported for inclusion in the MCMIS,135 even though the accident file is 

intended to be a census of fatal injury- and property damage-only accidents. Although the 

accident file contains State-supplied data from police reports involving drivers and 

vehicles of all motor carriers operating in the United States, an FMCSA evaluation of the 

database found that the overall reporting level of fatal and nonfatal involvements was 

lower than expected for both trucks and buses, at 63 percent and 44 percent, respectively. 

As a result, the FMCSA has contracted with the University of Michigan Transportation 

Research Institute to monitor and evaluate improvements in accident reporting by the 

States and resulting effects on the quality of MCMIS data.

At the Safety Board public hearing, the FMCSA reported that it has recognized the 

difficulty in obtaining meaningful motorcoach and bus fire data and has contracted with 

the Volpe Center to gather data and studies relating to motorcoach fires, set up a database 

or spreadsheet system to structure the data, and analyze the motorcoach and bus fire 

134 Manual on Classification of Motor Vehicle Traffic Accidents, section 2.4.18.

135 National Transportation Safety Board, Analysis of Intrastate Trucking Operations, Safety Report 

NTSB/SR-02/01 (Washington, DC: NTSB, 2002).
Analysis 56 Highway Accident Report

problem, including causes, frequency, and severity.136 Although the Safety Board supports 

this initiative and looks forward to the anticipated completion of the Volpe study in March 

2007, the Board is concerned that the gathering and analysis of bus and motorcoach fire 

data by the FMCSA Volpe contract will not provide for ongoing statistical compilation 

and study. The Safety Board concludes that continuing analysis of motorcoach and bus 

fire data is vital to understanding not only the trends in these vehicle fires, but also the 

success or shortcomings of measures taken by the Government and private industry to 

address this problem. Therefore, the Safety Board believes that the FMCSA should 

establish a process to continuously gather and evaluate information on the causes, 

frequency, and severity of bus and motorcoach fires and conduct ongoing analysis of fire 

data to measure the effectiveness of the fire prevention and mitigation techniques 

identified and instituted as a result of the Volpe National Transportation Systems Center 

fire safety analysis study.

Fire Propagation Into Fuel Sources

When fire burns in a confined space, the heat feedback from surroundings causes 

the material to burn more intensely. In this accident, the heat radiated by the glowing hub 

components and the confinement of the rubber tire within the wheel well significantly 

increased the rate at which the fire burned. From the burning 3R tire, the fire spread to 

adjacent tires, to other combustible wheel well area components,137 and to the composite 

exterior of the motorcoach. In addition, significant amounts of diesel fuel from the fuel 

delivery system became involved and accelerated the spread of the fire during the 

incipient stage.

In the accident motorcoach, the fuel lines were routed through a centerline tunnel 

in the undercarriage. Two small access panels made of a combustible material separated 

the fuel lines from the wheel well. One access panel was completely consumed by fire, 

and the other was partially melted and deformed. The thermoplastic fuel lines were 

completely consumed by fire from the engine compartment to a point within 1 foot of the 

fuel tank. In motorcoaches, fuel lines located near engine compartments and service 

tunnels can burn through and provide volatile fuel to an existing fire, causing a significant 

increase in the fire hazard. In this accident, burnthrough occurred once the tire fire 

breached the two combustible access panels to the service tunnel and the fuel lines in the 

engine compartment. Therefore, the Safety Board concludes that, because of the proximity 

of the combustible access panels to the tire wheel well, where the fire originated, the fuel 

delivery system contributed to acceleration of the fire.

Replacement of the combustible access panel with a fire-resistant barrier might 

preclude the early involvement of fuel in a fire in the wheel well area and thereby limit the 

rate of fire spread. NHTSA has developed a fuel system crashworthiness standard 

(FMVSS 301) to limit the amount of fuel spill as a result of an accident and thus reduce 

the chance of a catastrophic postcrash fire. However, this FMVSS does not apply to 

motorcoaches. Therefore, the Safety Board believes that NHTSA should develop an 

136 Motor Coach Fire Safety Analysis Work Plan.

137 These components include bushings, mud flaps, and suspension system air bags.
Analysis 57 Highway Accident Report

FMVSS to provide enhanced fire protection of the fuel system in areas of motorcoaches 

and buses where the system may be exposed to the effects of a fire. During the Safety 

Board’s public hearing, the office director for the rulemaking section of NHTSA’s 

Crashworthiness Standards Division stated that FMVSS 302138 is a performance (not 

design) requirement that “allows the latitude of the manufacturers so that the motorcoach, 

or any other type of a motor vehicle manufacturer, has the latitude to develop any 

innovative technologies.” Accordingly, until NHTSA has developed a performance 

standard for enhanced fire protection of fuel systems in newly manufactured 

motorcoaches and included it in the FMVSSs, as requested in Safety Recommendation 

H-07-4, the Safety Board believes that manufacturers of motorcoaches for use in the 

United States should use materials and designs for fuel system components that are known 

to provide fire protection for the system.

Fire Propagation Into Passenger Compartment

The most likely point of initial entry of a fire into a motorcoach is burnthrough of 

the combustible exterior composite materials just above the passenger-side rear wheel 

well area, followed by movement into the passenger compartment via both the HVAC 

system and the windows. In the case of a tire fire, the geometry of the wheel well and the 

buoyant nature of fire cause the flames to impinge on the sidewall; this exposure to severe 

heat is what leads to burnthrough of the combustible sidewall materials. In the accident 

motorcoach, the panels inside the wheel well area (those facing the roadway) were lined 

with stainless steel, which acted as a barrier to the fire. However, as the fire intensified 

above the wheel well, it burned through the exterior composite material and underlying 

sidewall foam insulation. The HVAC ventilation ductwork that ran along the sides of the 

motorcoach at the floor level opened a path for the fire and smoke, as evidenced by the 

destroyed recirculation duct in the right-rear wheel area and the aluminum return ducts 

and adjoining parts that showed signs of severe heat exposure. The missing sections had 

been located above the wheel well areas on both sides of the motorcoach.

During the public hearing, the senior technical advisor for the motorcoach 

manufacturer MCI noted that body panels on coaches have been made of aluminum, steel, 

or fiberglass for many years and that both aluminum and fiberglass are combustible 

materials. The MCI representative further stated, “We provide an interior inner fender 

barrier between the tire area and the passenger compartment. It is always made out of 

stainless steel.” He explained that the exterior of the vehicle is the most prominent path of 

fire into the interior as flames travel up the outside and past the windows, superheating the 

windows and causing them to break, allowing entry into the passenger compartment.

The burnthrough of the exterior wall allowed the fire’s intense heat and smoke—

byproducts of the burning tires, foam, and fiberglass—to enter the passenger 

compartment, where interior components also began to catch on fire. The propagation of 

the fire into the passenger compartment and the burning of interior components caused an 

exponential increase in the production of smoke and heat and accelerated the fire. The 

138 This standard specifies burn resistance requirements for materials used in the occupant compartment 

of motor vehicles.
Analysis 58 Highway Accident Report

Safety Board concludes that the tire fire, caused by an overheated right-side tag axle wheel 

bearing assembly, which ignited the tire, spread up the side of the motorcoach and burnt 

through the fiberglass sidewall above the wheel well and through the motorcoach 

windows, creating an entry path for the smoke and fire into the passenger compartment.

The Federal standard for flammability of interior materials, FMVSS 302, does not 

apply to the exterior of motor vehicles.139 The standard evaluates a material’s capability of 

resisting ignition and flame spread when exposed to a small ignition source, such as a 

match or a lit cigarette. It does not represent fire conditions where significant preheating 

of the material occurs and the ignition source is large. Additionally, the standard only tests 

materials in the horizontal orientation, which is a far less challenging test than the vertical 

orientation.

MCI’s senior technical advisor stated during the public hearing that MCI uses 

materials throughout the coach, including exterior sidewall components, that comply with 

FMVSS 302. However, as is clear from this accident, the compliance of the exterior 

sidewall materials to this standard was inconsequential to resisting the rapid propagation 

of the fire, which impeded the passengers’ ability to safely evacuate. Therefore, the Safety 

Board concludes that the exterior of the motorcoach had not been fire-hardened in fireprone areas, such as around the wheel wells, and was not required to be by regulation, 

thereby limiting the time available for safe egress in the event of a fire. The Safety Board 

believes that NHTSA should develop an FMVSS to provide fire-hardening of exterior 

fire-prone materials, such as those in areas around wheel wells, to limit the potential for 

flame spread into a motorcoach or bus passenger compartment.

Tire Fires and Fire Suppression Systems

As several witnesses at the Safety Board public hearing explained, and as 

documented during the motorcoach tire fire testing in August 2006, it is extremely 

difficult, and beyond the capacity of any practical, currently available hand-held chemical 

extinguisher or automatic fire suppression system, to completely extinguish a burning tire. 

Although the accident motorcoach driver was not able to unlatch the 5-pound dry 

chemical fire extinguisher, this type of fire extinguisher, as noted during the public hearing 

and the tire fire testing, cannot extinguish a tire fire and therefore would not have made a 

difference in this accident.

Various manufacturers currently sell automatic fire detection and suppression 

systems for transit and intercity motorcoaches140 that target engine compartment and 

electrical system fires. According to the testimony of an MCI senior technical advisor at 

the public hearing, the number of MCI motorcoaches being sold with fire suppression 

systems has increased.141 These systems generally employ spot heat detectors and a fire 

suppression agent distribution network with individual nozzles near the heat sensors. 

139 Title 49 CFR 571.302 applies to passenger cars, multipurpose passenger vehicles, trucks, and buses.

140 New Jersey Transit has been using vehicles with fire detection and suppression systems since 1994.

141 In addition, MCI has introduced the SmarTire pressure temperature monitoring system as an option 

in its motorcoaches.
Analysis 59 Highway Accident Report

However, none of these systems have been specifically designed to protect against and 

extinguish a tire fire. As the vehicle fire suppression systems product manager with 

Amerex Corporation stated at the public hearing, one way to prevent a fire may be to use 

a heat monitoring system to provide the driver with a prefire warning alert to elevated 

heat in a wheel well. In addition, future wheel well fire suppression systems might be 

designed to preempt the outbreak of a fire by monitoring the tires to detect dangerously 

high temperature conditions, at which point a fire suppression agent could be used to cool 

the tire.

In July 2006, the FMCSA announced a demonstration project initiative that will 

use state-of-the-art thermal imaging technology, integrated with signature recognition 

software, to identify faults and failures in tires, brakes, and bearings mounted on 

commercial motor vehicles. The contract for this 2-year project was awarded in 

September 2006. Additionally, the FMCSA is working with the Volpe Center to identify 

ways to prevent, reduce, or mitigate the severity and frequency of motorcoach fires, 

including the assessment of available fire suppression systems.

The Safety Board concludes that because tire fires are difficult to extinguish, early 

detection of potentially hazardous conditions in a wheel well area is critical, as 

demonstrated by the sequence of events in this accident, to eliminating the fire hazard. 

The Safety Board believes that NHTSA should develop detection systems to monitor the 

temperature of wheel well compartments in motorcoaches and buses to provide early 

warning of malfunctions that could lead to fires. Additionally, the Safety Board believes 

that NHTSA should evaluate the need for an FMVSS that would require installation of fire 

detection and suppression systems on motorcoaches.

Vehicle

Global did not retain vehicle maintenance and repair records as required by the 

FMCSRs. Although Global had been subleasing the motorcoach for a few months prior to 

the accident and had conducted some repairs and one preventative maintenance servicing, 

it did not have in place any maintenance program to properly service the vehicle. Without 

pretrip inspections or the required DVIRs, Global could not ensure that the vehicle was 

safe to operate on a daily basis.

The absence of maintenance and repair records prevents verification that vehicles 

are properly inspected and maintained. For several years before the accident, Global had 

failed to properly maintain repair records and provide routine maintenance servicing for 

its motorcoaches. On April 10, 2002, the TxDPS conducted an intrastate educational 

review of Global and found the company to be in violation for failing to maintain vehicle 

inspection and maintenance records. When the FMCSA conducted a 2004 compliance 

review, Global was cited for violating 49 CFR 396.3(b)(2) because the carrier did not have 

a means of indicating the nature and date of inspection and maintenance operations that 

were performed on its vehicles. When the FMCSA conducted a postfire compliance 

review on October 7, 2005, Global was cited for failing to inspect and maintain vehicles to 
Analysis 60 Highway Accident Report

ensure safe and proper operating conditions. Based on this compliance review, the 

FMCSA served Global with an operations OOS order, stating: “Global Limo has a grossly 

ineffective or nonexistent inspection, repair, and maintenance program.”

The accident motorcoach had received preventative maintenance service once 

while being operated by Global. When interviewed, the accident driver stated that he did 

not conduct pretrip inspections and did not check the oil level in the hub cavity. Global’s 

owner stated that he did not pay drivers to conduct pretrip or posttrip vehicle inspections. 

Because they did not conduct posttrip inspections and complete the DVIRs, as required by 

the FCMSA, neither the driver nor the carrier was alerted to potential vehicle defects 

requiring maintenance or repair.

The accident vehicle maintenance manual specifies that hub oil levels need to be 

checked daily. Some motorcoach models have a “sight glass” that allows observation of 

the oil level in the hub cavity; though the glass often becomes obscured and prevents an 

accurate view of oil levels, it can be cleaned or replaced. A wheel seal leak on a tag axle, 

however, can be observed only by inspecting the inside of the wheel for oil from a position 

underneath the motorcoach. The current design of the tag axle wheel hub makes it difficult 

for a roadside safety inspector to check for a wheel seal leak without an undercarriage 

vehicle inspection. The Safety Board concludes that because neither Global nor its 

employees routinely inspected the hub oil level or undercarriage of the wheel well, they 

did not discover the lack of lubrication of the tag axle wheel bearings; and this disregard 

for vehicle maintenance, pretrip inspections, and posttrip DVIRs led to a wheel bearing 

failure that resulted in a catastrophic fire and loss of life.

Although manufacturers recommend checking the wheel bearing lubricating oil 

levels daily, drivers are not specifically required to do so during a pretrip or posttrip 

inspection. However, proper routine maintenance would reveal inadequate hub oil levels 

or verify the absence of a wheel seal leak. Moreover, though neither roadside nor annual 

periodic inspections require checking the sight glass or the wheels for a leak, 49 CFR 

396.3 specifies, “Every motor carrier shall systematically inspect, repair, and maintain, 

or cause to be systematically inspected, repaired, and maintained, all motor vehicles 

subject to its control.” The regulations go on to state, under 396.5, “Every motor carrier 

shall ensure that each motor vehicle subject to its control is: (a) properly lubricated; and 

(b) free of oil and grease leaks.” Title 49 CFR 393.205 addresses the parts and 

accessories for safe operation of wheels and sets forth additional requirements for wheel 

seal and other hub leaks.

The industry acknowledges that a motorcoach tire fire is the most difficult to 

extinguish; though detection systems may alert a driver to a potential fire situation, 

adequate suppression systems are not yet available. Therefore, fire prevention is the key 

objective. The FMCSA has established specific OOS criteria for commercial vehicles in 

response to safety hazards, and it is the appropriate agency to require that commercial 

vehicles maintain proper wheel bearing lubrication to prevent failure and possible 

catastrophic tire fires.
Analysis 61 Highway Accident Report

A comprehensive program of proper maintenance by motor carriers, pretrip 

inspections, posttrip vehicle inspections by drivers, State and Federal requirements, and 

inspections to verify motor carrier compliance with safety regulations is necessary to 

prevent motorcoach fires. However, no regulations are in place that set inspection 

requirements for wheel bearings and wheel seal leaks. According to the FMCSA, the 

Volpe Center will assess the adequacy of current motorcoach operational inspection 

practices, both daily and periodic, as they relate to detecting and remedying situations that 

may lead to a fire.142

The Safety Board concludes that Federal regulations and inspection criteria do not 

require inspection of wheel bearings and adequate lubrication to prevent wheel bearing 

failure and a resulting wheel well fire. The Safety Board believes that the FMCSA should 

revise the FMCSRs at 49 CFR 393.205 to prohibit a commercial vehicle from operating 

with wheel seal or other hub lubrication leaks.

The maintenance manuals published by motorcoach manufacturers afford another 

means of fostering owner awareness of the risks associated with improper wheel bearing 

maintenance. MCI, the manufacturer of the accident motorcoach, placed caution and 

warning text boxes throughout its maintenance manual to provide additional information 

on the potential hazards of failing to properly maintain specific vehicle components and 

on methods for handling heavy vehicle parts. The manual cautioned that wheel seal 

integrity could be affected by excessive wheel bearing end play and lead to bearing or seal 

failure; no warning was given on the potential consequences of failing to maintain 

adequate wheel bearing lubrication, though daily checks of hub oil levels were 

recommended.

Maintenance guidance on vehicle components is based on manufacturers’ 

recommendations because they are in the best position to understand how their products 

work, including the consequences of not performing proper maintenance. Although the 

maintenance manual for the accident motorcoach included various warnings, none 

focused on the lubrication of wheel bearings. The Safety Board concludes that, in the 

absence of a specific warning in the maintenance manual, owners of vehicles with oil bath 

bearings may not be aware of the inherent danger of inadequate wheel bearing lubrication 

and the potentially serious consequences of a wheel bearing failure. The Safety Board 

believes that MCI should revise its product maintenance manuals to emphasize the 

importance of wheel bearing lubrication, specifically warning that daily inspection of hub 

oil levels and wheel seals is vital to prevent wheel bearing failure and that bypassing this 

requirement is a dangerous practice that can lead to a wheel well fire or other serious 

consequences. For those vehicles already sold and in service, the Safety Board believes 

that MCI should disseminate a customer advisory bulletin on the importance of proper 

wheel bearing maintenance, specifying the type of equipment or oil bath bearings that 

require an undercarriage inspection to detect wheel seal leaks and alerting customers to 

the serious consequences of lack of lubrication and subsequent wheel bearing failure.

142 Motorcoach Fire Safety Analysis Work Plan.
Analysis 62 Highway Accident Report

As principal purveyors of vehicle safety information, the United Motorcoach 

Association and the American Bus Association need to inform their members of the 

dangers inherent in improper maintenance of wheel bearings and the consequences of 

catastrophic wheel well fires. The Safety Board believes that the United Motorcoach 

Association and the American Bus Association should disseminate to their motorcoach 

and bus operator members an advisory bulletin emphasizing the importance of proper 

wheel bearing maintenance, particularly the importance of checking the oil level in oillubricated bearings (also known as oil bath bearings) and inspecting the undercarriage of 

the tag axle wheels to detect wheel seal leaks, and the serious consequences of lack of 

lubrication and subsequent wheel bearing failure.

The Safety Board also believes that the United Motorcoach Association and the 

American Bus Association should advise their motorcoach manufacturer members to 

review product maintenance manuals and, if the manuals do not emphasize the importance 

of wheel bearing lubrication, to revise them to specifically warn that daily inspection of 

hub oil levels and wheel seals is vital to prevent wheel bearing failure and that bypassing 

this requirement is a dangerous practice that can lead to a wheel fire or other serious 

consequences. Further, the Safety Board believes that the United Motorcoach Association 

and the American Bus Association should advise their motorcoach manufacturer members 

to disseminate, for those vehicles already sold and in service, a customer advisory bulletin 

on the importance of proper wheel bearing maintenance, specifying the type of equipment 

or oil bath bearings that require an undercarriage inspection to detect wheel seal leaks and 

alerting customers to the serious consequences of lack of lubrication and subsequent 

wheel bearing failure.

Bus Brokers

BusBank, the company that entered into a contract with Sunrise to obtain 

motorcoach transportation from Bellaire to another Sunrise facility on September 22, 

2005, is a bus broker. According to the FMCSA, it does not have the authority to regulate 

brokers of motor carriers that transport passengers; bus brokers are exempt from the 

Secretary of Transportation’s jurisdiction. Although the FMCSA does have the authority 

to require brokers to maintain a bond or insurance, as needed, to protect passenger 

carriers, neither the FMCSA nor the DOT has imposed an insurance requirement.143

At the Safety Board public hearing, BusBank testified that it performs a due 

diligence check on the motor carriers it contracts with for service. However, this check 

consisted only of verification of the required FMCSA insurance coverage and review of 

FMCSA-issued safety ratings available on the Internet. At the time of the accident, Global 

was listed as a motor carrier of passengers with a satisfactory FMCSA safety rating. The 

verification performed by BusBank uncovered no safety issues that would have alerted it 

to potential safety risks to the traveling public.

143 The FMCSA has stated that without the authority to require registration of brokers, it has no way of 

identifying them and monitoring their compliance with the insurance requirement.
Analysis 63 Highway Accident Report

Any member of the public can perform his or her own due diligence check on a 

motor carrier of passengers by contacting the FMCSA or searching the FMCSA 

website.144 The website also provides a link to detailed information on passenger carrier 

safety and on evaluating the safety practices of interstate motorcoach companies, such as 

those related to driver qualifications, limitations on driving, vehicle standards, 

subcontracting agreements, insurance requirements, carrier operating authority, and 

carrier insurance and safety information.

Although the BusBank website describes the company as “event specialists with 

local knowledge of bus availability, [and] bus quality,”145 its information is gathered from 

much of the same FMCSA data available to the traveling public. The selection of a motor 

carrier of passengers and the quality of information gathered by both bus brokers and the 

general public is ultimately dependent on the information and safety ratings issued by the 

FMCSA.

Federal Motor Carrier Safety Administration

On April 10, 2002, a TxDPS intrastate educational review of Global uncovered 

numerous driver and vehicle safety violations. In February 2004, an FMCSA compliance 

review of Global found similar violations of the FMCSRs pertaining to commercial 

drivers and vehicles, though the final safety rating for the carrier was satisfactory. After 

the Wilmer accident in September 2005, when the FMCSA conducted a second 

compliance review of Global, it issued the company a safety rating of unsatisfactory, 

declared that Global’s operations created an “imminent hazard” to public safety, and 

issued an operations OOS order. The order was based on Global’s numerous driver 

qualification violations and FMCSA documentation of Global’s lack of vehicle 

maintenance, inspection, and repairs, which resulted in vehicles that were mechanically 

unsafe. The FMCSA OOS order stated that Global’s pattern of FMCSR violations was 

consistent in nature and long in history. Although the February 2004 compliance review 

had documented many of the same safety violations as the postaccident compliance 

review 19 months later, the FMCSA issued a different final rating of Global, an 

unsatisfactory rating.

At the time of the accident, Global was not providing proper safety oversight of its 

operations. The accident driver had been working for Global without being properly 

licensed to drive a motorcoach in the United States, and after the accident, Global failed to 

conduct the postaccident alcohol and illicit drug testing required by the FMCSRs. Further, 

Global had been operating a passenger-carrying commercial vehicle, under an expired 

temporary trip permit tag, that was not registered in the United States, was displaying the 

license plate from another vehicle, and had not been systematically maintained. In light of 

these findings, as well as the violations found by the FMCSA during the postaccident 

144 See “Safe Transportation of Passengers by Motorcoach—and What It Means to You,” 

<www.fmcsa.dot.gov/safetyprogs/bus.htm>, December 5, 2006.

145 See <www.busbank.com>, December 1, 2006.
Analysis 64 Highway Accident Report

compliance review, the Safety Board concludes that Global exhibited a lack of concern for 

safety management controls by violating several Federal safety regulations pertaining to 

its drivers and vehicles, including employing a driver who was not properly licensed to 

drive a motorcoach in the United States, failing to conduct the required postacccident 

alcohol and illicit drug testing, and operating a passenger-carrying commercial vehicle, 

which had an expired temporary trip tag, that was not registered in the United States, was 

displaying the license plate from another vehicle, and had not been systematically 

maintained. This accident is one of many in which the Safety Board has focused on 

FMCSA safety oversight of motor carriers and has found inconsistencies based on a safety 

rating process that fails to ensure the removal of unsafe motor carriers from the Nation’s 

highways.146

In reviewing the FMCSA’s safety rating system within the compliance review 

process, the Safety Board has found the rating methodology inadequate in two areas:

• It considers only those violations defined by the FMCSA as “critical” or 

“acute” in determining a carrier’s overall safety rating, and

• It does not factor in a carrier’s driver’s rate of OOS orders and does not fully 

review vehicle inspection data.

The FMCSA compliance review uses a computer tabulation program to identify 

adherence to the FMCSRs for each rating factor, placing weighted numerical value only 

on violations of acute or critical regulations. Unrated violations—those that are noncritical 

or nonacute—are not given weight and therefore are not factored147 into the tabulation; the 

FMCSA does not consider a motor carrier’s violations of many FMCSRs to be an 

indication of safety management practices. In other words, if a carrier displayed a pattern 

of 100 percent noncompliance for every nonrated safety regulation violation, its overall 

safety rating would not be affected. This rating methodology is inconsistent with the 

FMCSA’s stated purpose of the compliance review, which is to make sure that a motor 

carrier has adequate safety management controls in place to ensure compliance with all 

applicable Federal safety requirements.

The Volpe Center reported that for the year 2005, the FMCSA performed 8,097 

Federal compliance reviews, during which a total of 61,924 violations of Federal safety 

regulations were found.148 However, only 1,758 violations were classified “acute,” and 

146 (a) National Transportation Safety Board, Motorcoach Run-off-the-Road and Overturn, Victor, 

New York, June 23, 2002, Highway Accident Report NTSB/HAR-04/03 (Washington, DC: NTSB, 2004).

(b) National Transportation Safety Board, Collision Between Truck-Tractor Semitrailer and School Bus 

Near Mountainburg, Arkansas, May 31, 2001, Highway Accident Report NTSB/HAR-02/03 (Washington, 

DC: NTSB, 2002). (c) National Transportation Safety Board, Selective Motorcoach Issues, Special 

Investigation Report NTSB/SIR-99/01 (Washington, DC: NTSB, 1999).

147 When asked during the Safety Board public hearing about how the FMCSA determines whether an 

FMCSR violation by a motor carrier is acute, critical, or unrated, an FMCSA field administrator stated that 

the agency determines certain regulations to be critical or acute depending on the relative risks of an 

accident (whether violation of those particular regulations would place a carrier at risk for an accident).

148 See MCMIS March 31, 2006, snapshot, <ai.fmcsa.dot.gov/ProgramMeasures/CR/NR/NSR/Report.asp?FC=

C&RF=T.>, October 20, 2006.
Analysis 65 Highway Accident Report

7,102 were classified “critical”—which is to say that 85.7 percent of Federal safety 

regulations violations discovered in 2005 did not carry any weight against the carriers’ 

safety ratings. Further, 65 percent of the 8,097 Federal compliance reviews conducted 

resulted in satisfactory ratings for the carriers, though 53,069 “other” (nonacute and 

noncritical) violations (85.7 percent) of Federal safety regulations were documented. The 

FMCSA documented violations in 7,831 (96.7 percent) of the compliance reviews.

At the Safety Board public hearing, the FMCSA field administrator stated that the 

agency is working with the Volpe Center to develop a risk model for all FMCSRs to 

make a determination as to whether a violation should be “critical” or “acute” for a 

compliance review safety determination. Although this study is a step in the right 

direction, the Safety Board has long taken the position, as expressed in its reports cited 

earlier, that violations of safety regulations are an indication of a motor carrier’s lack of 

safety management controls. The Safety Board concludes that the FMCSA’s compliance 

review program does not assign numerical value to safety regulation violations that are 

classified as neither “acute” nor “critical” during the safety fitness rating process, thereby 

allowing potentially unsafe carriers, which violate safety regulations without 

consequence, to continue operating.

The two most important factors in safe motor carrier operations are the operational 

status of the vehicles (trucks or buses) and the performance of the individuals who drive 

them. However, the FMCSA compliance review process does not accurately determine a 

motor carrier’s safety fitness because it does not factor in the rate of a carrier’s driver OOS 

orders from roadside inspections, and it includes only a limited amount of vehicle 

inspection data. Increasing the weight of performance data for driver and vehicle factors in 

compliance reviews is important because deficiencies in these factors are directly related 

to accidents. In previous accident investigations, the Safety Board has found that several 

unsafe carriers were permitted to continue operating as a result of a final satisfactory 

safety rating, regardless of driver- or vehicle-related safety violations.

In 1995, for example, the Safety Board investigated an accident in Indianapolis, 

Indiana,149 in which a motorcoach overturned when it entered an exit ramp; 2 passengers 

were killed, and 13 were seriously injured. The FHWA’s Office of Motor Carriers (now the 

FMCSA) conducted a postaccident compliance review of the operator, Hammond Yellow 

Coach Lines, Inc. (Hammond), which resulted in an unsatisfactory rating (10 out of 10 

vehicles reviewed were placed out of service). Hammond had had significant safety 

problems before the accident and yet was still permitted to operate. From 1987–1995, the 

Office of Motor Carriers had inspected Hammond nine times, and the carrier continued to 

receive final safety fitness ratings of satisfactory, even though several compliance reviews 

documented hours-of-service violations and high numbers of vehicles (63 percent) 

meeting OOS criteria. Following the Indianapolis accident, the Safety Board 

recommended that the DOT

149 NTSB/SIR-99/01.
Analysis 66 Highway Accident Report

H-99-6

Change the safety fitness rating methodology so that adverse vehicle or 

driver performance-based data alone are sufficient to result in an overall 

unsatisfactory rating for the carrier.

On December 14, 1999, the FHWA responded that it expected to issue an NPRM 

that would establish a more performance-based means of determining carrier fitness to 

conduct commercial motor vehicle operations. The agency stated that it would take into 

account the Safety Board’s recommendation, including any comments received, in 

developing a new system. On March 17, 2000, based on the expected NPRM, the Safety 

Board classified Safety Recommendation H-99-6 “Open—Acceptable Response.” The 

recommendation is on the Safety Board’s List of Most Wanted Transportation Safety 

Improvements.150

On September 4, 2002, the Safety Board reiterated Safety Recommendation H-99-6

to the DOT as a result of its investigation into an accident in Mountainburg, Arkansas,151

in May 2001, when a commercial truck, operated by Stuart Trucking (Stuart), collided 

with a school bus and killed three children. The postaccident FMCSA compliance review 

of the motor carrier resulted in an overall conditional rating; however, the FMCSA staff 

did not inspect any vehicles during this review, in spite of the fact that the accident was 

vehicle related. The FMCSA relied instead on the motor carrier profile report, which 

listed 29 roadside inspections in the previous 12 months,152 resulting in 4 OOS vehicles 

(14 percent). The Safety Board asked the Missouri Division of Motor Vehicles and 

Railroad Safety to conduct an additional review of the carrier and inspect all of its 

vehicles. Of 12 vehicles examined, 5 had OOS violations (42 percent). The 2001 

conditional rating for Stuart underscores the failure of compliance reviews to identify 

unsafe carriers. At the time of the accident, Stuart had not been rated in more than 11 years.

Despite having unsafe vehicles on the road and numerous driver violations, Stuart 

received a conditional rating (not “unsatisfactory”) even after the accident.

In June 2002, the Safety Board investigated an accident in Victor, New York,153 in 

which a motorcoach ran off the road and overturned because the driver fell asleep at the 

wheel. Five passengers were killed, and the driver and 41 passengers were injured. The 

FMCSA conducted a postaccident compliance review of the operator, Arrow Line, Inc. 

(Arrow), which resulted in a conditional rating (not “unsatisfactory”). Yet the compliance 

review revealed that Arrow had a 40 percent OOS rate for its vehicles, and the FMCSA 

noted that Arrow’s compliance review revealed noncompliance with the FMCSRs “in 

almost all applicable parts to Arrow Line, Inc.’s passenger transportation operation.”

150 The Safety Board’s “Most Wanted” list is a program to increase the public’s awareness of and 

support for action to adopt safety steps that can help prevent accidents and save lives.

151 NTSB/HAR-02/03.

152 At the time of issuance of the Safety Board report, in 2002, the FMCSA would not conduct a terminal 

inspection if 3 or more of a company’s vehicles had received roadside inspections in the previous 12 

months. The Safety Board recommended that the FMCSA require that a motor carrier’s fleet be inspected 

during compliance reviews (Safety Recommendation H-02-16).

153 NTSB/HAR-04/03.
Analysis 67 Highway Accident Report

Had Global’s driver and vehicle factor violations in the February 2004 compliance 

review resulted in an unsatisfactory rating, the carrier would have had only 45 days to 

correct the problems or cease operations. Instead, Global received a satisfactory rating and 

continued to operate and to violate safety regulations for drivers and vehicles; the FMCSA 

did not again review Global’s safety management practices until the accident occurred in 

September 2005. In the 2 years prior to the Wilmer accident, Global had accrued a driver 

OOS rate of 50 percent (8 roadside inspections resulted in 4 drivers being placed out of 

service), compared to the national rate of 6.6 percent. The accident driver himself had 

undergone three roadside inspections prior to the accident and had been placed out of 

service in two of the three. Although the motorcoach fire was the result of poor vehicle 

maintenance, had Global been rated “unsatisfactory” in February 2004 based on driver 

OOS rates and vehicle safety violations, as the Safety Board recommended in Safety 

Recommendation H-99-6, the company quite likely would not have been operating. If the 

FMCSA compliance review rating methodology were revised to give appropriate weight 

to driver and vehicle safety areas, the FMCSA would have accurate information regarding 

a carrier’s level of passenger safety; under such conditions, Global (like Arrow, Stuart, and 

Hammond before it) may have received an unsatisfactory rating.

Following the Safety Board’s September 2002 reiteration of Safety 

Recommendation H-99-6, the FMCSA advised that it intended to issue an NPRM on the 

safety fitness rating methodology in late 2003. In June 2004, the FMCSA notified the 

Safety Board that it anticipated making a final determination concerning changes to the 

safety fitness rating methodology in 2004. The FMCSA indicated that it was considering 

whether to seek additional comments through a supplemental advance NPRM or to 

proceed directly to an NPRM. The FMCSA expected to complete the rulemaking process 

in 2005. In a report issued in April 2006, the Safety Board expressed disappointment that 

the FMCSA had not acted on Safety Recommendation H-99-6 and stated its concern that 

the long time between the issuance of the recommendation and final action by the FMCSA 

jeopardizes the safety of the traveling public through unnecessary exposure to possibly 

unsafe commercial motor vehicles.154 On June 15, 2006, the FMCSA briefed the Safety 

Board on the CSA 2010 Initiative, which the agency indicated will include a complete 

evaluation of the compliance review process, leading to development of a new 

performance-based operational model for determining motor carrier safety, with emphasis 

on preventative measures and early detection of unsafe driver and carrier conditions.

At the August 2006 Safety Board public hearing, the FMCSA stated that it is 

reviewing the compliance review process and safety rating methodology. The FMCSA 

explained that when it originally promulgated the safety fitness determination process, the 

driver OOS rate information was found to be insufficient to accurately determine a 

driver’s safety performance; however, the FMCSA’s current goal is to develop a datadriven safety fitness determination process, which includes items such as vehicle and 

driver OOS rates, as part of its comprehensive examination of compliance review and 

enforcement oversight. Additionally, in September 2006, the FMCSA reported that it is 

154 National Transportation Safety Board, Multivehicle Collision on Interstate 90, Hampshire–Marengo 

Toll Plaza Near Hampshire, Illinois, October 1, 2003, Highway Accident Report NTSB/HAR-06/03 

(Washington, DC: NTSB, 2006).
Analysis 68 Highway Accident Report

developing a new safety fitness rating methodology based on an objective measure of 

driver or carrier safety performance data and will issue ratings on all drivers and carriers 

for which there are sufficient data. According to the CSA 2010 Initiative website, the 

deployment date of the new operational model is year 2010. The FMCSA plans to develop 

and draft legislation required for the program; rulemaking within the FMCSA takes at 

least 2 years. Pilot testing is projected to begin in 2008; pilot tests and training for 

deployment and implementation are expected to take at least 2 years and thus may extend 

well beyond 2010.

Concerned that motor carriers with significant regulatory violations for drivers 

and vehicles are still receiving satisfactory ratings, the Safety Board once more focuses 

on Federal standards for determining the safety fitness of carriers. As it has done in 

several accident investigations in the past 8 years, the Safety Board again concludes that 

the current FMCSA compliance review process does not effectively identify unsafe 

motor carriers and prevent them from operating. Full evaluation and implementation of 

the CSA 2010 Initiative will not be completed until 2010 or later, 10 years after the 

Safety Board first issued Safety Recommendation H-99-6. Accidents such as the Wilmer 

motorcoach fire, with high loss of life, underscore the need and the urgency for the 

FMCSA to move forward more expeditiously on this recommendation to remove unsafe 

motor carriers from the Nation’s highways. Therefore, the Safety Board reiterates Safety 

Recommendation H-99-6. 

Although the FMCSA has stated that the conceptual model for CSA 2010 is 

significantly different from the current operational model in that safety fitness 

determinations will be independent of the compliance review, the expected time frame for 

implementation of the new program is at least several more years. In the interim, 

deficiencies in the current compliance review system should be remedied to help prevent 

unsafe carriers from continuing to operate. The FMCSA is responsible for ensuring that 

motor carriers operate safely, and temporary measures to improve the compliance review 

process may be necessary until new rules are enacted. The FMCSA has already set 

precedent for the issuance of interim rules to improve safety programs; in 1997, the 

agency issued an interim final rule to immediately improve the safety rating methodology 

without prior notice and comment, stating that to have done otherwise would have been 

contrary to the public interest. Therefore, to protect the traveling public until completion 

of the CSA 2010 Initiative, the Safety Board believes that the FMCSA should 

immediately issue an Interim Rule to include all FMCSRs in the current compliance 

review process so that all violations of regulations are reflected in the calculation of a 

carrier’s final rating.

The Safety Board examined whether the inability of the motorcoach driver to 

communicate in English was a factor in this accident. Although the driver did not speak 

English, one of the nursing staff was able to sufficiently communicate with him in Spanish. 

Further, though the accident driver did not respond verbally to the motorist who informed 

him that the wheel well was glowing orange-red, he immediately took action to pull over 

onto the shoulder of the interstate. When the driver exited the motorcoach to inspect the tire, 

he was accompanied by several of the nursing staff, who also observed the flames. The 
Analysis 69 Highway Accident Report

driver and the nursing staff reacted to the emergency and immediately began evacuating 

passengers. Therefore, the Safety Board concludes that although the accident motorcoach 

driver had previously been cited in a roadside inspection as being a non-English-speaking 

driver, his inability to speak the English language was not a factor in this accident. The 

Safety Board was pleased when, in December 2006, the FMCSA provided information on 

research the agency has initiated into the issue of the English language proficiency 

requirement for commercial motor vehicle drivers. The FMCSA contracted with the Volpe 

Center to assess “the extent to which commercial motor vehicle drivers must be capable of 

communicating in English to ensure the safe operations of their vehicles on the Nation’s 

highways.” The FMCSA and the Volpe Center will interview and survey Federal and State 

enforcement personnel, motor carrier industry groups, individual motor carriers and drivers, 

State driver licensing agencies and highway departments, and highway safety advocacy 

groups. The FMCSA anticipates completion of the final research report by October 2007.

Survival

Motorcoach Emergency Egress

During the investigation of this motorcoach accident, the Safety Board identified 

problems with emergency egress from the vehicle. Although the motorcoach was 

equipped with emergency egress windows, they were not used in the evacuation because

• The nursing staff had not been instructed on the availability of the window 

exits and how to use them, and they were unaware of their potential as a means 

of exit during the evacuation.

• Most of the passengers who required assistance during the evacuation had 

special needs, and negotiating the movements necessary to escape through the 

emergency windows and the front door was all but impossible during the 

limited time available.

The rapid propagation of the fire and the heavy, thick black smoke afforded those 

patient-passengers seated beyond the third row little or no opportunity to be evacuated or 

rescued once the fire ignited combustible elements within the passenger compartment. 

The intense heat from the fire, coupled with the oppressive smoke, cut off all practical 

egress in a matter of minutes. The Safety Board concludes that the quick-spreading fire 

and thick smoke prevented nursing staff, bystanders, and rescuers from extricating all 

passengers with special needs from the accident motorcoach.

Two options are available to prevent fatalities in highway accidents: prevent the 

accidents or protect vehicle occupants when accidents do occur (survivability). By 

examining occupant survivability in motorcoach accidents, the DOT can identify means of 

increasing survivability. Surviving an accident depends on many factors. The structural 

integrity of the vehicle and passenger compartment, seat design, and restraint systems can 

all increase a person’s likelihood of surviving a crash. Fire-retardant materials, exit design, 

and prompt evacuation can assist persons in escaping a vehicle. For example, in aviation, 
Analysis 70 Highway Accident Report

Safety Board recommendations have provided the impetus for many improvements in 

occupant protection, including fire detection and suppression systems in aviation 

lavatories and cargo compartments, modifications in cargo compartments to delay fire 

spread, and fire blocking of cabin and seat materials.155

Evacuation Studies

For more than 30 years, the Safety Board has addressed the issue of motorcoach 

emergency evacuations.156 Although the DOT conducted emergency evacuation trials of 

intercity buses in 1976, no industry- or Government-sponsored research on emergency 

evacuation of motorcoaches has taken place since then. Motorcoach designs still 

incorporate the same window exit heights and combustible construction material that 

prevailed decades ago. The Safety Board has long held that the capability of rapidly 

evacuating motorcoaches in emergencies is essential.

Although motorcoach and bus fire data are inconsistent in current accident 

databases, the FMCSA, commercial insurance companies, and the industry generally 

acknowledge that the number of fires is increasing. Yet today, decades after release of the 

1976 and 1984 DOT reports on evacuation of intercity buses157 and evacuation of elderly and 

disabled passengers from paratransit vans and buses,158 motorcoaches are still essentially 

constructed of the same combustible materials and present the same evacuation issues.

Motorcoaches transport large numbers of people in a confined space. Panic can 

quickly ensue when occupants are threatened by fire or smoke in an unfamiliar or 

enclosed environment. Smoke, panicked reactions, unfamiliarity with motorcoach 

components, and inadequate exit design can hamper the efficient and safe use of 

emergency exits. The Wilmer accident demonstrates that, just as in airplane and passenger 

train fires, the danger to passengers is not limited to the flames themselves but also can 

result from the side effects of a fire, such as inhaling smoke. In the Wilmer accident, 

passengers died because of injuries caused by smoke inhalation, in addition to thermal 

injuries caused by the fire.

Unlike in the aviation industry, motorcoaches, which can accommodate 55 or more 

passengers, are not required to perform full-scale evacuation drills. Just as passengers 

seated in an airplane or in a railcar are called upon to operate the emergency exits in an 

evacuation, passengers in a motorcoach are expected to operate exits in the event of an 

emergency. However, research shows that under the stress of an evacuation, passengers do 

155 National Transportation Safety Board, Survivability of Accidents Involving Part 121 U.S. Air Carrier 

Operations, 1983 Through 2000, Safety Report NTSB/SR-01/01 (Washington, DC: NTSB, 2001).

156 (a) National Transportation Safety Board, Interstate Bus–Automobile Collision, Interstate Route 15, 

Baker, California, March 7, 1968, Highway Accident Report NTSB/SS-H-3 (Washington, DC: NTSB, 

1968). (b) National Transportation Safety Board, Greyhound Bus Collision With Concrete Overpass Support 

Column on Interstate 80, San Juan Pass, Sacramento, California, November 3, 1973, Highway Accident 

Report NTSB/HAR-74/05 (Washington, DC: NTSB, 1974). (c) National Transportation Safety Board, 

Docket No. SRH-96-FH-015.

157 Evacuation of Intercity Buses.

158 Evacuation and Rescue of Elderly and Disabled Passengers From Paratransit Vans and Buses.
Analysis 71 Highway Accident Report

not necessarily use the most appropriate exit. Passengers in such situations are less able to 

cope with new equipment and information; their natural inclination is to leave by the exits 

they recognize, such as the front loading door. Under stress, passengers may have 

difficulty figuring out the method of window operation if it is not intuitive or does not 

match their immediate expectations.159 The use of emergency window exits in a 

motorcoach is not intuitive; the hinged windows do not remain open, and the drop to 

ground is 7–8 feet. Safe and effective evacuation with minimal panic requires that 

passengers be provided with a basic understanding of the function of exits.

Although the staffing level on the accident motorcoach was sufficient to provide 

routine care of the patient-passengers (for example, dispensing medications and 

monitoring the well-being of residents), once the emergency situation arose, the health 

care staff was insufficient to safely and rapidly evacuate the motorcoach. The ADA 

ensures equal opportunity and accessibility for persons with disabilities to public 

conveyances, whether for routine transportation needs or educational and social group 

outings. Moreover, typically many sightseeing excursions sponsored by senior citizens’ or 

children’s groups include passengers with limited mobility or physical handicaps. 

Motorcoach charters often include passenger populations that have a significant number 

of persons with special needs. The Federal Government needs to address the ability of 

persons with special needs to rapidly egress from a motorcoach or bus in an emergency 

situation. The DOT has not studied this issue or published related research since the 1984 

report, Evacuation and Rescue of Elderly and Disabled Passengers From Paratransit 

Vans and Buses.

The Safety Board has used the airEXODUS model to simulate evacuation from a 

wide-body aircraft with only 8 exits and 440 passengers; limiting the number of exits used 

can have a dramatic effect on evacuation times. The airEXODUS model is a highly 

specialized software tool originally developed to model the complex interactions of 

aircraft configuration and passenger behavior in emergency evacuations.160 Not all exits 

are typically available during an escape situation in airplanes, railcars, or motorcoaches. 

The limited available statistics on motorcoach fires indicate that the rear of the 

motorcoach (engine compartment and rear wheel wells) experiences the majority of fires 

and that the windows normally provide the fire pathway into the passenger compartment. 

As was the case with the accident motorcoach, not all exit windows are likely to be 

available for escape,161 depending on the circumstances of the emergency, such as fire, 

submersion in water, collision damage, rollover, or operational failure.

159 Sharon Cook and Dean Southall, PSV Emergency Exits: Passenger Behaviour and Exit Design, 

United Kingdom Department of Transport (London, UK: ICE Ergonomics Ltd., 1997) 5.

160 Richard W. Bukowski, Richard D. Peacock, and Walter W. Jones, Sensitivity Examination of the 

airEXODUSTM Aircraft Evacuation Simulation Model (Gaithersburg, MD: National Institute of Standards 

and Technology, 1998) 7.

161 According to the Safety Board’s interviews of the nursing staff, they had covered the windows with 

newspaper and could not see the latches; the newspaper caught on fire as the flames entered the passenger 

compartment.
Analysis 72 Highway Accident Report

In December 2001, the FRA published an interim report on the fire safety of 

passenger trains.162 In the analysis of passenger railcar fire performance, the minimal 

principal acceptance criterion was considered to be the minimum necessary egress time 

for a fully loaded passenger car, assuming an orderly, unimpaired evacuation. If the 

minimum necessary egress time is less than the time available for safe egress for all design 

fires, the design is considered acceptable. As stated in the report, “like the 90-second 

certification testing for aircraft, this minimum necessary egress time is simply a consistent 

point of comparison for different passenger railcar configurations and fire scenarios.” In 

addition, the FRA, through the Volpe Center, is conducting a project related to passenger 

trains and fires, calling upon the Building and Fire Research Laboratory at the National 

Institute of Standards and Technology (NIST) for expertise in the development of models 

for the simulation of fires and associated hazards and risks for the broader application of 

fire hazard analysis to passenger train transportation.163

The FAA has also studied the use of computer simulation models to evaluate 

commercial aircraft evacuations. Fire hazard analysis using simulations can determine the 

fire performance of the entire aircraft fire protection and evacuation system by modeling 

both the fire environment and passenger egress.164

Using existing technology and building on the DOT research for aviation and 

railcar passengers, evacuation trials and computer simulation analyses can expand the 

application of fire safety analysis to the passenger population throughout the 

transportation system. Research and evacuation studies are needed to document and 

analyze actual evacuation scenarios, such as darkness, fire- and smoke-impaired vision, 

and water submersion, involving all types of passenger populations that require difficult 

and time-sensitive evacuations.

Emergency Exit Design

The Safety Board has investigated accidents involving motorcoaches with 

emergency windows, such as on the accident motorcoach, that are approximately 7–8 feet 

from the ground, hinged at the top, and operated by lifting a release bar and pushing 

outward.165 In several of these investigations, emergency responders and bystanders had 

difficulty rescuing passengers because of window height and top-hinge design, just as 

bystanders reported in the Wilmer accident.

For example, on June 20, 1998, a 1997 MCI motorcoach operated by Greyhound 

Lines, Inc., was traveling westbound on the Pennsylvania Turnpike near Burnt Cabins, 

Pennsylvania,166 when it ran off the right side of the roadway and struck the back of a 

162 U.S. Department of Transportation, Federal Railroad Administration, Fire Safety of Passenger 

Trains, Phase II: Application of Fire Hazard Analysis Techniques, DOT/FRA/ORD-01/16 (Washington, DC: 

FRA, 2001).

163 Sensitivity Examination of the airEXODUSTM Aircraft Evacuation Simulation Model.

164 Sensitivity Examination of the airEXODUSTM Aircraft Evacuation Simulation Model.

165 (a) NTSB/SS-H-3. (b) NTSB/HAR-74/05. (c) NTSB Docket No. SRH-96-FH-015.

166 National Transportation Safety Board, Greyhound Run-Off-the-Road Accident, Burnt Cabins, 

Pennsylvania, June 20, 1998, Highway Accident Report NTSB/HAR-00/01 (Washington, DC: NTSB, 2000).
Analysis 73 Highway Accident Report

tractor semitrailer. The entire front of the motorcoach was crushed, and the front loading 

door was destroyed; the motorcoach driver and 6 passengers were killed, and 16 passengers 

were injured. The emergency responders reported difficulty in rescuing the trapped 

passengers and had to set up a ladder to reach the emergency windows. The Safety Board 

determined that when passersby and emergency responders arrive on scene to rescue trapped 

passengers and provide medical assistance, any impediment to rapid entry into the accident 

vehicle can be detrimental to timely treatment of injuries and passenger survival. In the 

Wilmer accident, witnesses interviewed by the Safety Board reported trying to open the 

motorcoach windows from the exterior. When two passersby could not reach high enough to 

pry open two windows, they broke the windows but were unable to rescue any passengers.

Past Safety Board investigations have involved passengers of diverse ages and 

physical abilities who reported difficulty in evacuating because the windows were heavy and 

they could not hold them open while attempting to climb out and descend unassisted 8 feet to 

the ground. The majority of passengers in the Wilmer accident were persons with special 

needs, were unable to evacuate on their own, and could not be rescued before the fire 

destroyed the motorcoach; in other emergency situations, however, window height and design 

could impede the timely egress of passengers responding to a rapidly propagating fire.

On July 29, 1997, for example, a 1985 TMC motorcoach operated by Rite-Way 

Transportation, Inc., drifted off the side of Interstate 95 near Stony Creek, Virginia,167 and 

down an embankment into the Nottoway River, where it came to rest on its left side, 

partially submerged in water. The front of the motorcoach was severely damaged, and the 

vehicle immediately began to fill up with water. Many passengers had to swim to the 

surface to escape. Some of the passengers, as young as 11, were too small to push the 

heavy emergency windows open far enough to evacuate. The Safety Board concluded that 

the strength and height needed to open an emergency window when a motorcoach is not 

upright pose a problem for some passengers, especially children, senior citizens, and 

injury victims. The Safety Board recommended that NHTSA

H-99-9

Revise the Federal Motor Vehicle Safety Standard 217, “Bus Window 

Retention and Release,” to require that other than floor-level emergency 

exits can be easily opened and that they remain open during an emergency 

evacuation when a motorcoach is upright or at unusual attitudes.

The Safety Board added this recommendation to the List of Most 

Wanted Transportation Safety Improvements in 2000,168 and it is currently classified 

167 NTSB/SIR-99/01.

168 NHTSA originally responded to the Safety Board by letter on April 15, 1999, stating that the agency 

would research a “hold open” device for all emergency exit windows that are hinged at the top and 

determine whether the device would satisfy the conditions set forth in the Safety Board’s recommendation. 

If not, NHTSA stated that it intends “to perform research to establish the feasibility of a device that will limit 

the forces required to open emergency windows and keep emergency exit windows open when the bus its on 

its side. When the above is complete, NHTSA will then propose changing Standard 217 to require this 

device on emergency exit windows on buses and school buses.”
Analysis 74 Highway Accident Report

“Open—Acceptable Response.” On October 12, 2006, NHTSA wrote to the Safety Board 

and stated that, as part of the regular 7-year regulatory review process, it is studying 

FMVSS 217 and anticipates completion of the review by early 2007.

The rapid propagation of fire and quickly spreading smoke call for prompt, orderly 

egress of all motorcoach passengers. The circumstances of the Wilmer accident—a rapidly 

spreading fire, inadequate motorcoach egress systems, and destruction of the vehicle—

along with the increasing number of tire fires noted by the industry, highlight the critical 

need to evaluate the adequacy of current motorcoach emergency egress design. In any 

such evaluation, passenger negotiation of the 7–8 foot window drop as a means of escape 

cannot be ignored. Many motorcoach window exits are 8 feet above ground, a distance 

higher than the wings of some airplanes, such as the 727, 737, and Canadair regional jet. 

Federal regulations require an approved means to assist airplane passengers in descending 

from an exit that is higher than 6 feet above ground; however, no such Federal regulations 

are in place for motorcoach exit heights. The Safety Board concludes that, in the absence 

of demonstrated emergency evacuation capabilities for motorcoaches, such as the accident 

vehicle, the effectiveness of design features in facilitating the safe escape of passengers 

cannot be determined. The Safety Board believes that NHTSA should evaluate current 

emergency evacuation designs of motorcoaches and buses by conducting simulation 

studies and evacuation drills that take into account, at a minimum, acceptable egress times 

for various postaccident environments, including fire and smoke; unavailable exit 

situations; and the current above-ground height and design of window exits to be used in 

emergencies by all potential vehicle occupants.

Oxygen Cylinders

To avoid dangerous rupture or explosion, a pressure relief device in oxygen 

cylinders, such as a burst disk, is designed to actuate when the internal pressure in the 

cylinder reaches 3,025–3,360 psig. As designed, when a fully pressurized cylinder is 

heated to 260o–315o F, its internal pressure exceeds the actuation pressure (3,025–3,360 

psig) of the burst disk, and a controlled release of oxygen occurs to prevent cylinder 

rupture. Representatives of aluminum cylinder manufacturers stated to Safety Board 

investigators that, though aluminum melts at 1,020o–1,206o F, the exposure of the 

cylinders to temperatures well below the melting range will weaken the aluminum. A fully 

pressurized aluminum cylinder without a burst disk will maintain its integrity for only 

minutes at temperatures above 600o F because of the increased pressure levels acting on 

the now heated and structurally weakened aluminum cylinder.

Federal HM regulations on pressure relief devices are designed for the 

transportation of full cylinders. The regulations require that a pressure relief device 

prevent the failure of a fully pressurized cylinder in a fire; however, they do not consider 

cylinders that are partially pressurized. Prior to 1981, this omission was not a problem 

because all specification cylinders permitted for the transportation of compressed gas 

were manufactured of steel, which is not as sensitive as aluminum to material strength loss 

when exposed to heat. In 1981, the HM regulations were amended to permit aluminum 
Analysis 75 Highway Accident Report

cylinders for use in transporting compressed gases. Because of the potential loss of 

material strength, the Safety Board is concerned that an aluminum cylinder might rupture 

at an internal pressure well below the actuation pressure of the burst disk.

The Safety Board’s analysis indicated that, though the burst disk on a heated, 

fully pressurized cylinder actuates as designed before failure of the cylinder (that is, 

before the aluminum weakens and loses integrity), a partially pressurized heated cylinder 

can fail before the burst disk actuates. Specifically, when a cylinder containing less than 

78 percent of its full charge (1,570 psig at room temperature) is heated to a temperature 

exceeding 400o F, it will structurally fail before its internal pressure actuates the burst 

disk. Thus, partially pressurized aluminum cylinders exposed to heat are more likely to 

rupture before the internal pressure is high enough to actuate the burst disk. When the 

aluminum weakens and the cylinder loses integrity (the cylinder wall fails), though the 

internal pressure is not high enough to actuate the burst disk, it causes the cylinder to fail, 

releasing the oxygen and causing the fragmented pieces of the cylinder to become 

hazardous projectiles.

During this accident investigation, three aluminum cylinders retrieved from the 

motorcoach were found with intact valves, even though two cylinders displayed 

evidence of melting, and one had fractured and burst. Upon examination of the burst 

disks for these three cylinders, the Safety Board determined that two cylinders failed 

before the burst disks actuated. Such failures would have rapidly released large 

quantities of oxygen into the fire and may have propelled portions of the cylinders some 

distance from the point of origin. In fact, the intense burst of fire shown in figure 6, a 

still photograph from video footage of the motorcoach fire, was likely caused by the 

failure of one of these two cylinders. Emergency responders and passersby described 

these bursts of fire as “explosions.”

The Safety Board considered what effect, if any, the venting and failure of these 

cylinders had on the attempted rescue of passengers remaining in the motorcoach. 

According to the Safety Board’s study, the first cylinder failure, which likely caused a 

burst of fire, would not have occurred until the temperature of the cylinder was at least 

400o F. First responders and passersby who were attempting to rescue passengers reported 

ceasing their efforts just before, or just as, these bursts began to occur.

By the time the temperature levels were high enough to cause two aluminum 

cylinders to fail, the heat from the fire in the rear of the motorcoach prevented rescuers 

from safely reaching the passengers seated there. Further, heavy, black smoke from the 

fire inside the motorcoach was reported to have been overwhelming within only a few 

minutes of the passenger evacuation and prevented rescue attempts beyond the first few 

rows of seats. The Safety Board concludes that the smoke and heat from the fire prevented 

rescuers from safely proceeding further into the motorcoach within minutes of their arrival 

on scene and that the aluminum cylinders failed, releasing oxygen to the fire, after 

successful rescue attempts were no longer possible.

The rupture of aluminum cylinders caused by internal pressure exceeding the 

strength of the cylinder wall poses a significant hazard to emergency responders and 
Analysis 76 Highway Accident Report

others. Aluminum cylinders can be transported as cargo in any mode of transportation, and 

the presence of aluminum cylinders containing any compressed gas may pose a significant 

hazard in transportation fires.

PHMSA recommends limiting the number of cylinders to the extent practicable 

and limiting the total weight of cylinders to 99 pounds per vehicle;169 however, these 

limitations may not be practicable in an emergency evacuation, such as in advance of a 

hurricane. Should aluminum cylinders be an issue for emergency responders in any mode 

of transportation, the safety of the vehicle occupants and the responders is of the utmost 

priority. The Safety Board concludes that the possibility of structural failure in partially 

pressurized aluminum cylinders when exposed to heat and fire, as occurred on the 

accident motorcoach, poses a danger to the general public and emergency responders. The 

Safety Board believes that PHMSA should develop standards for the safe transportation of 

partially pressurized aluminum cylinders by, for example, requiring the addition of 

temperature-actuated pressure relief devices or the reduction of residual pressure to safe 

limits, to ensure that such cylinders do not experience overpressure failure when exposed 

to a fire.

Furthermore, the Safety Board believes that PHMSA should issue guidance to, at a 

minimum, the Fraternal Order of Police (FOP), International Association of Chiefs of 

Police (IACP), International Association of Fire Chiefs (IAFC), International Association 

of Fire Fighters (IAFF), National Association of State EMS Officials (NASEMSO), 

National Sheriffs’ Association (NSA), and National Volunteer Fire Council (NVFC), 

describing the risk of overpressure failure of partially pressurized aluminum cylinders and 

the steps that should be taken to protect responders and the general public from a vehicle 

fire when aluminum cylinders are present. In addition, the Safety Board believes that the 

FOP, the IACP, the IAFC, the IAFF, NASEMSO, the NSA, and the NVFC should 

disseminate to their members the guidance developed by PHMSA describing the risk of 

overpressure failure of partially pressurized aluminum cylinders and the steps that should 

be taken to protect responders and the general public from a vehicle fire when aluminum 

cylinders are present.

Emergency Evacuation of Persons With Special Needs

When Hurricane Rita became a threat to the Texas Gulf Coast in late September 

2005, it posed unique challenges to organizations and entities responsible for ensuring 

the safety of persons with special needs. In many emergencies, sheltering in place is 

recommended because of the hazards and difficulties involved in evacuating special 

needs populations consisting of medically frail individuals. However, the strength of 

Hurricane Rita, along with the risk it posed to persons and property, made evacuation the 

appropriate option.

169 U.S. Department of Transportation, Pipeline and Hazardous Materials Safety Administration, 

Guidance for the Safe Transportation of Medical Oxygen for Personal Use on Buses and Trains 

(Washington, DC: PHMSA, 2005).
Analysis 77 Highway Accident Report

When Sunrise officials tried to locate a nearby shelter to which the Brighton 

Gardens residents could evacuate in advance of Hurricane Rita, they learned that 

Hurricane Katrina evacuees occupied their preferred location, which was a facility closer 

than the 4-hour drive to Dallas, Texas. Lacking a nearby alternative to handle all of its 

residents, and being urged by the Bellaire fire marshal to evacuate, Sunrise determined 

that the best option was to travel to a more distant location capable of accommodating the 

residents. Sunrise monitored the evacuation situation on the news and learned that 

restrooms were unavailable in many locations, gasoline was in short supply, and many 

evacuees were stranded on the roadside. Paratransit buses designed for persons with 

special needs were considered unsuitable for this particular evacuation because of the 

limited number of seats and the lack of on-board restrooms. According to Sunrise, 

motorcoach transport became the best available option under the circumstances.

Hurricane Rita placed extraordinary pressures on evacuation transportation 

operations in coastal Texas, in part because of recent demands on limited emergency 

resources throughout the Gulf Coast region caused by Hurricane Katrina. Given the 

prospect of another devastating natural disaster, the evacuation of persons with special 

needs from nursing homes and other care facilities in the hurricane’s path was considered 

necessary, despite the lack of optimal transportation. Because of the high demand for 

evacuation transport, both State and private organizations had difficulty locating sufficient 

transportation.

For example, the State of Texas, through the TBPC, attempted to obtain 1,100 

buses and motorcoaches for evacuation purposes but was able to locate only 307 vehicles. 

Unaware that the TBPC had arranged transportation for Texas residents, including persons 

with special needs, Sunrise officials contracted with BusBank, which it had previously 

used when searching for transportation in advance of Hurricane Katrina. Had Sunrise 

officials been aware of State efforts to obtain and coordinate emergency transportation, 

they might have been able to meet their needs through the TBPC, though a bus or 

motorcoach provided by the TBPC might not have been demonstrably safer than the 

accident motorcoach. After all, the accident motorcoach had received a satisfactory rating 

from the FMCSA, suggesting that it met minimum safety requirements. Therefore, the 

Safety Board concludes that, given the unusual circumstances and limited options, Sunrise 

took reasonable action at the time in deciding to contract with BusBank for motorcoach 

transportation. Sunrise has since stated that it intends to develop a national bus and 

motorcoach contract for emergency evacuation of its facilities.

Efforts to improve planning for evacuation of persons with special needs are also 

under way at the State level. Shortly after Hurricane Rita, the Texas Governor established 

a Task Force on Evacuation, Transportation, and Logistics to review the hurricane 

evacuation and recommend improvements for evacuation plans and execution; in March 

2006, the Governor directed that all task force recommendations be implemented. Texas 

has now entered into contingency contracts with out-of-State motorcoach carriers and 

CUSA to provide 1,100 motorcoach-type buses for emergency evacuations.

Government agencies and organizations representing communities of persons with 

special needs are attempting to provide better information, both to long-term care industry 
Analysis 78 Highway Accident Report

members and to individuals with special needs (or their caregivers), on responding to 

emergencies that may require evacuation. In addition, in response to the 2005 hurricane 

disasters, private businesses, such as those operating nursing homes and long-term care 

facilities, have begun to improve their emergency transportation arrangements. For 

instance, the American Health Care Association has encouraged member facilities to 

make contingency arrangements for emergency evacuation transportation. The 

association’s draft “bus safety transport checklist,” to be included in its Disaster 

Preparedness Plan, even suggests that long-term health care facilities should provide 

backup arrangements for evacuation transportation in case the contingency 

contractor fails to provide transportation during an emergency, when market pressure 

may stress transport supplies.

The Office of the President, the DHS, the DOT, the GAO, the HHS, and other 

Federal agencies have studied the responses to both Hurricanes Katrina and Rita. These 

studies include recommendations for improving emergency evacuation of persons with 

special needs. To deal with transport supply shortfalls when the NRP and NDMS prioritize 

the limited number of ambulances for hospital evacuation, the DOT has developed a 

nationwide inventory of more than 100,000 buses and motorcoaches that its national 

contractor will use for emergency evacuations. In addition, the DOT is working with the 

American Bus Association to index the capabilities of the buses and motorcoaches, 

including the numbers of available evacuation-ready vehicles and drivers and their 

locations, as well as the vehicles’ configurations and equipment.

During its investigation into this accident and the subsequent public hearing, the 

Safety Board found that, since the 2005 hurricane season, many organizations have 

developed and disseminated information about emergency evacuation of persons with 

special needs. Government and private entities have also reviewed and evaluated disaster 

preparedness as it applies to persons with special needs. The results of these efforts appear 

on websites available to long-term care providers and anyone interested in ensuring the 

safety of persons with special needs in a disaster. Within the Federal Government, such 

websites include those of FEMA,170 the DHS,171 the DOT’s Office of Civil Rights,172 and 

the HHS.173 In addition, the website of the American Health Care Association174 offers for 

sale its Disaster Planning Guide: A Resource Manual for Developing a Comprehensive 

Preparedness Plan, developed by the Florida Disaster Preparedness Committee and the 

Florida Health Care Association. The website of the Joint Commission on Accreditation 

of Healthcare Organizations provides information in conjunction with its publication, 

170 See <www.fema.gov/plan/prepare/specialplans.shtm>, September 26, 2006.

171 For preparedness information for persons with special needs, see 

<www.ready.gov/america/getakit/disabled.html>, September 26, 2006. For developments from the HHS 

Interagency Coordinating Council on Emergency Preparedness and Individuals With Disabilities, see 

<www.dhs.gov/dhspublic/interapp/editorial/editorial_0591.xml>, September 26, 2006.

172 See <www.dotcr.ost.dot.gov/asp/emergencyprep.asp>, September 26, 2006.

173 Among other HHS publications issued following the 2005 hurricanes was Nursing Home Emergency 

Preparedness and Response During Recent Hurricanes. See <oig.hhs.gov/oei/reports/oei-06-06-00020.pdf> 

September 26, 2006.

174 See <www.ahca.org>, September 26, 2006.
Analysis 79 Highway Accident Report

Standing Together: An Emergency Planning Guide for America’s Communities,

175 which 

addresses the needs of “vulnerable” populations. Many other organizations, such as the 

American Red Cross176 and Easter Seals,177 offer information on their websites concerning 

emergency planning for persons with special needs.

The Safety Board is gratified that, following the disasters caused by Hurricanes 

Katrina and Rita, many government and private organizations have begun to improve 

evacuation systems by working to provide better means of emergency transportation, 

improving coordination among parties involved in the evacuation of persons with special 

needs, and disseminating emergency preparedness information to community members.

175 See <www.jointcommission.org/NR/rdonlyres/FE29E7D3-22AA-4DEB-94B2-5E8D507F92D1/0/ 

planning_guide.pdf>, September 26, 2006.

176 See <www.prepare.org/disabilities/disabilitiesprep.htm>, September 26, 2006.

177 See <www.easterseals.com/site/PageServer?pagename=ntl_safety_first_evacuation>, September 26, 

2006.)
80 Highway Accident Report

Conclusions

Findings

1. Although the hurricane evacuation was the reason for the trip, neither the weather 

conditions at the time nor the design and condition of the roadway caused or 

contributed to the accident.

2. A determination could not be made regarding the potential impact of the motorcoach 

driver’s medical condition on his response to the emergency.

3. The motorcoach driver was fatigued at the time of the tire fire, but his fatigue was not 

a causal factor in the accident.

4. Appropriate resources were dispatched to the accident scene, responders and medical 

personnel arrived as quickly as possible, considering the heavily congested roadways 

and the initially erroneous information about the accident location, and the injured 

received medical care and were transported to local hospitals in a timely manner.

5. The accident motorcoach was mechanically unsafe because the right-side tag axle 

wheel bearing assembly lacked sufficient lubrication, which resulted in high frictional 

forces and high temperatures, causing the wheel bearings to fail and igniting the tire.

6. Continuing analysis of motorcoach and bus fire data is vital to understanding not only 

the trends in vehicle fires, but also the success or shortcomings of measures taken by 

the Government and private industry to address this problem.

7. Because of the proximity of the combustible access panels to the tire wheel well, 

where the fire originated, the fuel delivery system contributed to acceleration of the 

fire.

8. The tire fire, caused by an overheated right-side tag axle wheel bearing assembly, 

which ignited the tire, spread up the side of the motorcoach and burnt through the 

fiberglass sidewall above the wheel well and through the motorcoach windows, 

creating an entry path for the smoke and fire into the passenger compartment.

9. The exterior of the motorcoach had not been fire-hardened in fire-prone areas, such as 

around the wheel wells, and was not required to be by regulation, thereby limiting the 

time available for safe egress in the event of a fire.

10. Because tire fires are difficult to extinguish, early detection of potentially hazardous 

conditions in a wheel well area is critical, as demonstrated by the sequence of events 

in this accident, to eliminating the fire hazard.
Conclusions 81 Highway Accident Report

11. Because neither Global Limo Inc. nor its employees routinely inspected the hub oil 

level or undercarriage of the wheel well, they did not discover the lack of lubrication 

of the tag axle wheel bearings; and this disregard for vehicle maintenance, pretrip 

inspections, and posttrip driver vehicle inspection reports led to a wheel bearing 

failure that resulted in a catastrophic fire and loss of life.

12. Federal regulations and inspection criteria do not require inspection of wheel bearings 

and adequate lubrication to prevent wheel bearing failure and a resulting wheel well 

fire.

13. In the absence of a specific warning in the maintenance manual, owners of vehicles 

with oil bath bearings may not be aware of the inherent danger of inadequate wheel 

bearing lubrication and the potentially serious consequences of a wheel bearing 

failure.

14. Global Limo Inc. exhibited a lack of concern for safety management controls by 

violating several Federal safety regulations pertaining to its drivers and vehicles, 

including employing a driver who was not properly licensed to drive a motorcoach in 

the United States, failing to conduct the required postaccident alcohol and illicit drug 

testing, and operating a passenger-carrying commercial vehicle, which had an expired 

temporary trip tag, that was not registered in the United States, was displaying the 

license plate from another vehicle, and had not been systematically maintained.

15. The Federal Motor Carrier Safety Administration’s compliance review program does 

not assign numerical value to safety regulation violations that are classified as neither 

“acute” nor “critical” during the safety fitness rating process, thereby allowing 

potentially unsafe carriers, which violate safety regulations without consequence, to 

continue operating.

16. The current Federal Motor Carrier Safety Administration compliance review process 

does not effectively identify unsafe motor carriers and prevent them from operating.

17. Although the accident motorcoach driver had previously been cited in a roadside 

inspection as being a non-English-speaking driver, his inability to speak the English 

language was not a factor in this accident.

18. The quick-spreading fire and thick smoke prevented nursing staff, bystanders, and 

rescuers from extricating all passengers with special needs from the accident 

motorcoach.

19. In the absence of demonstrated emergency evacuation capabilities for motorcoaches, 

such as the accident vehicle, the effectiveness of design features in facilitating the 

safe escape of passengers cannot be determined.
Conclusions 82 Highway Accident Report

20. The smoke and heat from the fire prevented rescuers from safely proceeding further 

into the motorcoach within minutes of their arrival on scene, and the aluminum 

cylinders failed, releasing oxygen to the fire, after successful rescue attempts were no 

longer possible.

21. The possibility of structural failure in partially pressurized aluminum cylinders when 

exposed to heat and fire, as occurred on the accident motorcoach, poses a danger to 

the general public and emergency responders.

22. Given the unusual circumstances and limited options, Sunrise Senior Living Services, Inc.,

took reasonable action at the time in deciding to contract with BusBank for 

motorcoach transportation.

Probable Cause

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 

posttrip 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.
83 Highway Accident Report

Recommendations

New Recommendations

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

following safety recommendations:

To the Federal Motor Carrier Safety Administration:

Establish a process to continuously gather and evaluate information on the 

causes, frequency, and severity of bus and motorcoach fires and conduct 

ongoing analysis of fire data to measure the effectiveness of the fire 

prevention and mitigation techniques identified and instituted as a result of 

the Volpe National Transportation Systems Center fire safety analysis 

study. (H-07-1)

Revise the Federal Motor Carrier Safety Regulations at 49 CFR 393.205 to 

prohibit a commercial vehicle from operating with wheel seal or other hub 

lubrication leaks. (H-07-2)

To protect the traveling public until completion of the Comprehensive 

Safety Analysis 2010 Initiative, immediately issue an Interim Rule to 

include all Federal Motor Carrier Safety Regulations in the current 

compliance review process so that all violations of regulations are reflected 

in the calculation of a carrier’s final rating. (H-07-3) 

To the National Highway Traffic Safety Administration:

Develop a Federal Motor Vehicle Safety Standard to provide enhanced fire 

protection of the fuel system in areas of motorcoaches and buses where the 

system may be exposed to the effects of a fire. (H-07-4)

Develop a Federal Motor Vehicle Safety Standard to provide fire-hardening 

of exterior fire-prone materials, such as those in areas around wheel wells, 

to limit the potential for flame spread into a motorcoach or bus passenger 

compartment. (H-07-5)

Develop detection systems to monitor the temperature of wheel well 

compartments in motorcoaches and buses to provide early warning of 

malfunctions that could lead to fires. (H-07-6)

Evaluate the need for a Federal Motor Vehicle Safety Standard that would 

require installation of fire detection and suppression systems on 

motorcoaches. (H-07-7)
Recommendations 84 Highway Accident Report

Evaluate current emergency evacuation designs of motorcoaches and buses 

by conducting simulation studies and evacuation drills that take into 

account, at a minimum, acceptable egress times for various postaccident 

environments, including fire and smoke; unavailable exit situations; and 

the current above-ground height and design of window exits to be used in 

emergencies by all potential vehicle occupants. (H-07-8)

To the Pipeline and Hazardous Materials Safety Administration:

Develop standards for the safe transportation of partially pressurized aluminum 

cylinders by, for example, requiring the addition of temperature-actuated

pressure relief devices or the reduction of residual pressure to safe limits, to 

ensure that such cylinders do not experience overpressure failure when 

exposed to a fire. (I-07-1)

Issue guidance to, at a minimum, the Fraternal Order of Police, 

International Association of Chiefs of Police, International Association of 

Fire Chiefs, International Association of Fire Fighters, National 

Association of State EMS Officials, National Sheriffs’ Association, and 

National Volunteer Fire Council, describing the risk of overpressure failure 

of partially pressurized aluminum cylinders and the steps that should be 

taken to protect responders and the general public from a vehicle fire when 

aluminum cylinders are present. (I-07-2)

To the Fraternal Order of Police, International Association of Chiefs of Police, 

International Association of Fire Chiefs, International Association of Fire Fighters, 

National Association of State EMS Officials, National Sheriffs’ Association, and 

National Volunteer Fire Council:

Disseminate to your members the guidance developed by the Pipeline and 

Hazardous Materials Safety Administration describing the risk of 

overpressure failure of partially pressurized aluminum cylinders and the 

steps that should be taken to protect responders and the general public from 

a vehicle fire when aluminum cylinders are present. (I-07-3)

To Motor Coach Industries, Inc.:

Revise your product maintenance manuals to emphasize the importance of 

wheel bearing lubrication, specifically warning that daily inspection of hub 

oil levels and wheel seals is vital to prevent wheel bearing failure and that 

bypassing this requirement is a dangerous practice that can lead to a wheel 

well fire or other serious consequences. (H-07-9)
Recommendations 85 Highway Accident Report

For those vehicles already sold and in service, disseminate a customer 

advisory bulletin on the importance of proper wheel bearing maintenance, 

specifying the type of equipment or oil bath bearings that require an 

undercarriage inspection to detect wheel seal leaks and alerting customers 

to the serious consequences of lack of lubrication and subsequent wheel 

bearing failure. (H-07-10)

To Motor Coach Industries, Inc., Prevost Car Inc., Setra, Van Hool, Blue Bird 

Corporation, Trident Industries, Inc., and IC Corporation:

Until the National Highway Traffic Safety Administration has developed a 

performance standard for enhanced fire protection of fuel systems in newly 

manufactured motorcoaches and included it in the Federal Motor Vehicle 

Safety Standards, as requested in Safety Recommendation H-07-4, use 

materials and designs for fuel system components that are known to 

provide fire protection for the system. (H-07-11)

To the United Motorcoach Association and the American Bus Association:

Disseminate to your motorcoach and bus operator members an advisory 

bulletin emphasizing the importance of proper wheel bearing maintenance, 

particularly the importance of checking the oil level in oil-lubricated 

bearings (also known as oil bath bearings) and inspecting the undercarriage 

of the tag axle wheels to detect wheel seal leaks, and the serious 

consequences of lack of lubrication and subsequent wheel bearing failure. 

(H-07-12)

Advise your motorcoach manufacturer members to review product 

maintenance manuals and, if the manuals do not emphasize the importance 

of wheel bearing lubrication, to revise them to specifically warn that daily 

inspection of hub oil levels and wheel seals is vital to prevent wheel 

bearing failure and that bypassing this requirement is a dangerous practice 

that can lead to a wheel fire or other serious consequences. (H-07-13)

Advise your motorcoach manufacturer members to disseminate, for those 

vehicles already sold and in service, a customer advisory bulletin on the 

importance of proper wheel bearing maintenance, specifying the type of 

equipment or oil bath bearings that require an undercarriage inspection to 

detect wheel seal leaks and alerting customers to the serious consequences 

of lack of lubrication and subsequent wheel bearing failure. (H-07-14)
Recommendations 86 Highway Accident Report

Reiterated Recommendations

The National Transportation Safety Board also reiterates the following two safety 

recommendations:

To the U.S. Department of Transportation:

Change the safety fitness rating methodology so that adverse vehicle or 

driver performance-based data alone are sufficient to result in an overall 

unsatisfactory rating for a carrier. (H-99-6)

Require motorcoach operators to provide passengers with pretrip safety 

information. (H-99-8)

BY THE NATIONAL TRANSPORTATION SAFETY BOARD

MARK V. ROSENKER DEBORAH A. P. HERSMAN

Chairman Member

ROBERT L. SUMWALT KATHRYN O’LEARY HIGGINS

Vice Chairman Member

STEVEN R. CHEALANDER

Member

Adopted: February 21, 2007

Member Hersman filed the following concurring statement on February 28, 2007, 

joined by Member Higgins. Member Higgins filed the following concurring and 

dissenting in part statement on April 20, 2007, and was joined concurring in part by 

Member Hersman.
Recommendations 87 Highway Accident Report

Notation 7774A

Member Deborah A. P. Hersman, Concurring:

There was almost nothing about this accident that was usual. The circumstances—

from the hurricane evacuation to the general health of the passengers to the traffic 

conditions—were extraordinary. Yet, the accident uncovered an astounding number of 

issues of motorcoach safety that we cannot afford to look past just because the accident 

happened under unusual circumstances. I will focus on just a few of the issues that were 

raised during our Board meeting on February 21, 2007 but are not thoroughly discussed in 

the final accident report.

Bus Driver’s English Language Deficiency

The bus driver was unable to communicate in English. Although the bus driver’s 

English language deficiency was not causal to the accident, it is nevertheless useful to 

look at how this deficiency had a tangential effect on the accident in several instances:

• A training video available at Global for training drivers was in English and 

would not have been useful to the bus driver.

• The MCI maintenance manual for the motorcoach was in English, making it of 

no use to the driver as far as items to look at during a pre-trip inspection, 

required maintenance, and proper vehicle operation.

• The driver was unable to read and interpret variable message boards on the 

highway giving information about routing and the evacuation. 

• The residential care director of Sunrise, who was riding in the bus and who 

knew a little Spanish, had difficulty communicating to the driver their need to 

stop the bus in order to replace depleted oxygen tanks for two of the passengers.

• The residential care director again had trouble communicating with the driver 

when trying to ascertain the milepost number of the place they stopped when 

the bus had a flat tire, so that she could notify the Navarro County Emergency 

Services dispatcher of their location. 

• When the mechanic arrived on scene to repair the flat tire, the driver was 

unable to converse with him about the repair.

• The bus driver at first had difficulty understanding the severity of the problem 

when another driver signaled to him that the bus’s rear tire was on fire. 

• The bus driver was unable to effectively communicate to the passengers the need 

for them to evacuate the bus quickly. According to a Safety Board investigator’s 

analysis report, it was only after the nursing staff communicated among 

themselves about the danger threatening the passengers that the bus evacuation 

began, mostly through the efforts of the nursing staff and bystanders.1

1 Human Performance Group Chairman’s Memorandum of Analysis, NTSB Accident no. 

HWY-05-MH-035.
Recommendations 88 Highway Accident Report

Federal Motor Carrier Safety Regulations (FMCSRs) require that an individual 

driving a commercial motor vehicle in the United States must be proficient in English.2

On February 12, 2005, the bus driver was stopped for a roadside inspection in which the 

inspector noted on the inspection report that the bus driver did not speak English. In 

accordance with 49 CFR 396.9(d), Global Limo had 15 days to correct this 

noncompliance, yet according to company records, the bus driver drove, not only on the 

day of the accident, but also on many trips between the February inspection and the day of 

the accident. 

Language has been a factor in several tragic accidents in the past several years. In 

2005, the Safety Board investigated a motorcoach fire near Meriden, Connecticut. The 

driver of the motorcoach saw the need for passengers to quickly evacuate the bus, but he 

spoke only Chinese and was unable to communicate an evacuation order. Eventually, the 

passengers were able to interpret his body motions and communicated to one another the 

need to evacuate. Last year, this same motorcoach operator was involved in an accident in 

Boston in which 48 people were injured. As in the earlier accident, a Chinese-speaking 

driver could not communicate in English. This time, FMCSA cited the company for 

violating the English language requirement, in addition to a speeding violation, and fined 

the company $31,000 for both violations.3

Effective communication is the foundation for a successful response to an 

emergency. In 2005, the Safety Board investigated a gasoline tanker rollover accident in 

Davie, Florida, in which the driver’s inability to speak English impeded first responders’ 

efforts to ascertain what type of hazardous material he was transporting in the tanker. In 

2003, the non-English speaking driver of a tractor semi-trailer involved in an accident near 

Slippery Rock, Pennsylvania, was unable to communicate to first responders the nature of 

his load when first responders noticed that the trailer, engulfed in flames, was placarded 

for hazardous materials. He reported through an interpreter that he had been unable to 

read variable message signs on the roadway, but that he just followed traffic. He also 

reported that he had been stopped twice for roadside inspections, in which case, he called 

his boss on his cell phone so that his boss could act as interpreter between him and the 

inspector. He was not cited for a violation of the English language requirement. 

A motorcoach accident near Manahawkin, New Jersey, in 2003 involved a driver 

who spoke Chinese and was unable to answer basic questions about the accident without a 

State Police interpreter. In an accident near Old Bridge, New Jersey, in 1998, the driver of 

a motorcoach was not able to provide needed basic information to investigating officers 

without a Russian interpreter. 

2 49 CFR 391.11(b)(2) states: “Except as provided in Subpart G of this part, a person is qualified to 

drive a motor vehicle if he/she can read and speak the English language sufficiently to converse with the 

general public, to understand highway traffic signs and signals in the English language, to respond to official 

inquiries, and to make entries on reports and records.”

3 News release, U. S. Department of Transportation, Office of Public Affairs, October 30, 2006.
Recommendations 89 Highway Accident Report

We cannot categorically state that if the language barrier in any of these 

accidents had been removed, the accidents would not have happened. However, it must 

be acknowledged that in these accidents, as in the accident in Wilmer, the situations 

would have been more effectively and safely handled had there not been a language 

issue. 

It is worthwhile to note that in 2003, the Commercial Vehicle Safety Alliance 

(CVSA) petitioned the Department of Transportation (DOT) to amend the FMCSRs to 

better address the language proficiency of commercial drivers.4 The petition cites the 

inability of some commercial drivers to communicate in English as compromising the 

inspection process as well as highway safety. CVSA suggested that the Federal Motor 

Carrier Safety Administration (FMCSA) work with CVSA to develop a standard test 

procedure for law enforcement officers to use to determine if a commercial driver meets 

the minimum standard for communication. CVSA also suggested that FMCSA revise the 

regulation at 49 CFR 391.11(b)(2) to reflect requirements for communication under the 

North American Free Trade Agreement under which it is the responsibility of a driver and 

a motor carrier to be able to communicate in the country in which they are operating so 

that safety is not compromised.

Bus Driver’s Immigrant Status and Mexican Commercial Driver’s License

The bus driver, a citizen of Mexico, was an illegal alien in the U.S. at the time of 

the accident. When asked by Safety Board investigators if he had a green card or a work 

visa, he responded that he did not. He stated that he held a commercial driver’s license in 

Mexico since 1988 and was an experienced bus driver in Mexico, having driven for his 

father’s (and later his brother’s) company for many years, but he came to the U.S. because 

of the “differences in pay.” At the time of the accident, he was driving under the authority 

of a Mexican CDL issued in 1998. As a driver with a Mexican CDL, he was permitted to 

drive from Mexico to the United States, or through the United States to Canada, and 

return. He was not legally permitted to drive from an origination point in the U.S. to a 

destination in U.S. as he was doing for Global Limo.

On the back of his CDL, boxes indicated “No” as the response to the following 

medical conditions: diabetes, vision correction required, and hypertension. Although the 

bus driver admitted being diagnosed with diabetes in 1998 and being treated by a Mexican 

physician for Type II diabetes, his CDL did not reflect that he has the illness. 

Investigators did not find any records associated with his CDL that reflected his condition 

had been disclosed or was under control. When a U.S. doctor declined to give him a 

medical certification until he could prove that his diabetes was controlled, he continued to 

drive under his Mexican CDL. 

4 Commercial Vehicle Safety Alliance to U.S. Department of Transportation, Federal Motor Carrier 

Safety Administrator, “Petition to Amend 49 CFR Part 391 to Facilitate Adequate Language Proficiency for 

Commercial Drivers,” September 10, 2003.
Recommendations 90 Highway Accident Report

The bus driver was cited twice for speeding, once in April 2005 near Brownsville, 

Texas and once in August, 2005 near Laredo, Texas (he said he was trying to make up lost 

time after the bus broke down on the trip).5 Neither citation appeared on his license at the 

time of the accident or any time during the investigation. If he had pleaded guilty and paid 

for either or both citations, they should have appeared as convictions on his Mexican 

CDL. If he had failed to pay the fines or appear in court, his license should have been 

suspended. Data improvement efforts over the last decade have resulted in significant 

investments in the Commercial Driver’s Licensing system. The goal of these federal 

investments is to guarantee that license and conviction information is transferred between 

the 50 states, the District of Columbia, Mexico, and Canada. For this purpose, a database 

has been established in the U.S. that connects to the Federal licensing system in Mexico 

and so that it functions as the “52nd State.” Investigators could not find documentation to 

determine whether the citations were resolved through the courts or the licensing system. 

In this case, the system that connects traffic citations to the drivers who commit them, 

from one country to the other, failed. 

While the bus driver’s immigration status was not causal to the accident, I believe 

that it did have a role in keeping a sloppy motorcoach operator in business. The bus driver 

knew that Global buses had chronic maintenance problems. The owner of the company 

had avoided recommended repairs, in one instance, departing a repair shop in Aransas 

Pass, Texas, with a parking brake that did not work. The owner had a reputation for 

failing to pay for repairs, and in fact, NTSB investigators found two Global buses being 

held as collateral at Valley Volvo in Pharr, Texas, because Global had neglected to pay for 

repairs. The accident bus driver reported that he had driven the accident bus to Dallas 

earlier in the week and that the air conditioner was not working and the front tires were so 

bald they were causing the front end of the bus to vibrate. He told investigators that he 

“demanded” that repairs be made before the next trip. The tires were replaced, however 

the new tires were undersized, which may have caused the front axle to be overloaded by 

as much as 33.6%.6 

The violations of FMCSRs accumulated by Global Limo are well documented. 

In the two years prior to the accident, Global’s drivers were subjected to eight roadside 

inspections that resulted in four drivers being placed out of service for hours-of-service 

violations. The driver of the accident bus underwent three roadside inspections prior to 

the accident and was placed out of service after two of the three inspections. Safety 

Board investigators learned that Global did not require drivers to keep a record of their 

hours of service, except when driving on behalf of FEMA. The driver said that he 

continued to work for Global because the company owed him several thousand dollars 

in back pay. He said he was promised his money once the company had more cash 

earned from contracts it had with FEMA to transport evacuees from New Orleans 

following Hurricane Katrina. 

5 Driver interview, Motor Carrier Groups Chairman’s Factual Report, Texas Department of Public 

Safety Citation, NTSB Accident No. HWY-05-M-H035.

6 Vehicle Group Chairman’s Factual Report, NTSB Accident No. HWY-05-M-H035.
Recommendations 91 Highway Accident Report

Both parties in this employer/employee relationship had deficiencies to hide and 

compensate for. The bus driver was an undocumented alien working illegally in this 

country with an apparently problematic foreign CDL with an invalid medical certification. 

He worked for Global because the company was willing to overlook his immigration 

status and other licensing problems. Global was a cash-strapped bus company operating 

in violation of numerous motor carrier safety violations. Global hired the bus driver 

because he was willing to overlook the company’s many safety issues so that he could 

work in this country. These two parties forged a symbiotic relationship that enabled this 

motorcoach company to operate on the thinnest of safety margins, until the day of this 

accident when the margin disappeared.

The Federal Motor Carrier Safety Administration

FMCSA was created by the Motor Carrier Safety Improvement Act of 1999 

(MCSIA). Prior to its establishment as an independent modal administration, the 

functions of FMCSA were housed in the Office of Motor Carriers (OMC) within the 

Federal Highway Administration (FHWA). Originally, authority for the trucking and 

motorcoach industries was administered by the Interstate Commerce Commission, but 

following deregulation and the passage of the Motor Carrier Act of 1980, economic and 

safety authority were divorced. The Motor Carrier Safety Act of 1984 directed the 

Secretary of Transportation to establish a procedure to determine the safety fitness of 

owners and operators of commercial vehicles operating in interstate commerce. It stated 

that the intent of Congress was to reduce commercial vehicle crashes and fatalities 

through strong enforcement of motor vehicle safety laws and regulations. Thus, the OMC 

became responsible for safety oversight of the truck and bus industry.

In the late 1990s, the OMC came under harsh criticism from safety groups, the 

Congress, and the DOT Inspector General for its failure to reduce large truck crashes and 

fatalities and for being too close to the trucking industry. The general conclusion was that 

the priorities of the truck and bus safety office were too buried within a huge agency, 

FHWA, whose primary mission was to build roads. According to the Inspector General, 

“The fatality rate for large truck crashes has remained flat since 1995, while the number of 

fatalities involved in those crashes continues to increase... The OMC has shifted emphasis 

from enforcement to a more collaborative, educational, partnership-with-industry 

approach to safety. This is a good approach for motor carriers that have safety as a top 

priority, but it has gone too far...”7 FHWA acknowledged in a response letter to the 

Inspector General that the “pendulum has swung too far towards education/outreach and 

now must move towards stronger enforcement, particularly for repeat offenders.” 8 

In May of 1999, DOT Secretary Rodney Slater and Federal Highway 

Administrator Kenneth Wykle announced a safety action plan with a goal of reducing 

motor carrier traffic fatalities by 50% over 10 years through a comprehensive effort with

7 Department of Transportation Inspector General Report No. TR-1999-091, April 26, 1999, Motor 

Carrier Safety Program, Federal Highway Administration.

8 Ibid.
Recommendations 92 Highway Accident Report

safety groups, industry and state and local governments.9 By September of 1999, they 

reported progress, citing a 59% increase in compliance reviews, followed by an increase 

in Federal investigators at the border from 13 to 40, and a reduction in the enforcement 

case backlog by two-thirds.10

Despite these actions by DOT, Congress quickly passed the MCSIA on a 

bipartisan basis,11 which President Clinton signed into law on December 9, 1999. The Act 

created FMCSA and directed it to “reduce the number and severity of large-truck involved 

crashes through more commercial motor vehicle and driver inspections and carrier 

compliance reviews, stronger enforcement, expedited completion of rules, sound research, 

and effective commercial driver’s license testing, recordkeeping, and sanctions.”12 The 

Act also authorized a large scale truck crash causation study, harsher penalties for 

violators, reviews of new motor carriers within 18 months of starting operations, 

improved data collection and reporting requirements, and substantial increases in funding 

for federal and state oversight efforts. 

FMCSA’s Budget

Along with the creation of an independent agency came significant increases in 

funding for motor carrier safety. As part of FHWA, OMC had existed as an office within a 

larger agency, but the stand-alone modal administration required additional funds for the 

overhead costs generated by such independence. In addition, FMCSA has received 

significant increases each year to hire additional inspectors, complete regulatory activity 

and improve motor carrier safety. Since the agency opened its doors on January 1, 2000, 

its annual appropriation has increased by over 250%.

9 http://www.dot.gov/affairs/1999/52599sp.htm, Remarks by Secretary Slater, Commercial Vehicle 

Safety Action Plan, May 25, 1999.

10 FHWA 61-99 Press Release, September 28, 1999, “U.S. Transportation Secretary Slater Reports 

Progress in Motor Carrier Safety.”

11 In August 1999 Senator McCain introduced S. 1501, The Motor Carrier Safety Improvement Act of 

1999 and Representatives Shuster, Oberstar, Petri and Rahall introduced H.R. 2679, The Motor Carrier 

Safety Act of 1999.

12 P.L. 106-159.
FMCSA Funding 2000-2007

181

272

361

305

364

443

490 490

0

100

200

300

400

500

600

2000 2001 2002 2003 2004 2005 2006 2007

Fiscal Year

Dollars in Millions

Recommendations 93 Highway Accident Report

Source:

2000 (http://testimony.ost.dot.gov/test/passttest/00test/Cirillo1.htm) 

2001 – 2002 (http://www.dot.gov/bib2003/fmcsa.html)

2003 – 2004 (http://www.dot.gov/bib2005/admins.html)

2005 – 2006 (http://www.dot.gov/bib2007/admins.html)

2007 (http://www.dot.gov/bib2008/bibpart06fmcsa.htm)

Performance Measures

FMCSA has established several performance measures and subjective data sets 

that provide useful information. One such data set reflects the number of fatalities in large 

truck crashes. One of the first goals set by FMCSA upon its creation was to reduce the 

number of fatalities involving large trucks by 50% in ten years. In the past eight years, 

however, the number of such fatalities has remained fairly constant. 
Large Truck Crash Fatalities

1999-2005 

5,380 5,282 5,111 4,939 5,036 5,235 5,212

0

1,000

2,000

3,000

4,000

5,000

6,000

1999 2000 2001 2002 2003 2004 2005

Fatalities

50% Reduction Target

Actual Fatalities

Recommendations 94 Highway Accident Report

Source:

1999-2004 -http:ai.volpe.dot.gov/test/CarrierResearchResults/HTML/2004Crashfacts/tb11.htm

2005 - http:ai.volpe.dot.gov/CrashProfile/n_overview.asp

As it became increasingly clear that the goal to achieve a 50% reduction in large 

truck fatalities was not going to be reached in the time allotted, the agency changed its 

goal. In DOT’s proposed Safe, Accountable, Flexible, and Efficient Transportation Equity 

Act in 2003, FMCSA’s “re-stated goal” was to participate in the DOT-wide goal of 

reducing the fatality rate in all motor vehicle crashes by 41% between 1998 and 2008. 

FMCSA’s part of that goal was to reduce commercial vehicle crash fatalities to 1.65 

fatalities per 100 million truck miles traveled (MTMT). In April 2005, Administrator 

Annette Sandberg testified before Congress about the new FMCSA goal to reduce 

commercial vehicle crash fatalities, stating, “I am pleased to report that the FY 2003 CMV 

fatality rate is the lowest recorded since the Department initiated tracking in 1975.”13

While the agency came closest to meeting its goal in 2003, the gap between the annual 

goal rate and the actual rate increased that year and each year after that. For example, in 

the FY 2007 budget submission, FMCSA stated that the goal for 2003 was a rate of 2.19, 

but the actual rate was 2.31. Similarly, in 2004, the goal rate was 2.07, but the actual rate 

was 2.29, and in 2005, the goal was 1.96, and the estimated rate was projected to be 2.33. 

FMCSA has not achieved its “restated goal.”

13 Adminstrator Annette Sandberg, Testimony before the Senate Commerce, Science and 

Transportation Committee, April 5, 2005.
Large Truck Fatality Rate per MTMT

2.19 2.32

2.45

1.96 2.07

2.30 2.31 2.29 2.28

2.45

0

0.5

1

1.5

2

2.5

3

2001 2002 2003 2004 2005

Year

Fatalities per 100 Million Truck Miles 

Traveled

Target 

Actual

Recommendations 95 Highway Accident Report

Source:

1999-2004 (http://ai.volpe.dot.gov/test/CarrierResearchResults/HTML/2004Crashfacts/tbl1.htm)

2005-2006 (http://www.whitehouse.gov/omb/expectmore/detail/10000410.2003.html)

In its FY 2008 budget estimates, FMCSA has once again changed the measure to 

evaluate its own effectiveness, with a new goal to be achieved by 2011.14 However, that 

goal is no longer expressed as the large truck fatality rate per 100 MTMT, but rather as the 

combined bus/large truck fatality rate per 100 million vehicle miles traveled (MVMT). It 

is important to note, that the agency has done two things to change the measure: first, it 

merged the fatality rate with the bus/motorcoach rate, and, second, it replaced the number 

of fatalities per 100 MTMT (which, of course, calculates only truck miles) in favor of a 

new exposure denominator comprising annually accrued mileage for all motor vehicles.

The bus/motorcoach fatality rates per 100 MVMT are far lower than those for 

trucks, so with the first change of merging bus/motorcoach fatality rates with truck rates, 

the combined rates were substantially lowered, with new figures expressed as the large 

truck-bus/motorcoach fatality rate per 100 million commercial motor vehicle miles 

traveled (CMVMT). In the second change, the exposure of total CMVMT was then 

submerged in the larger, total mileage traveled annually by all motor vehicles. Thus, 

FMCSA is able to portray a fatality rate that is more than an order of magnitude lower 

than the previous measure of large truck fatalities per 100 MTMT. Accordingly, instead of 

large truck fatality rates of 2.31 (2003), 2.37 (2004), and 2.34 (2005) per 100 MTMT, the 

rate stated in the FY 2008 budget estimates for 2005 (the earliest year cited in the body of 

14 “Budget Estimates Fiscal Year 2008,” Federal Motor Carrier Safety Administration, p. 4A-14.
Recommendations 96 Highway Accident Report

the FY 2008 budget estimates) is 0.184 per 100 MTVMT (million total vehicle miles 

traveled). Similarly, the target goal for 2006 is 0.179, for 2007 it is 0.175, and for 2008 it 

is 0.171. While some may question whether this exposure denominator is appropriate, 

what is clear is that in less than 10 years since it has been created, the total number of 

commercial vehicle fatalities has remained flat while the agency has thrice revised its 

goals, making it very difficult for anyone to make meaningful year-to-year comparisons 

and obfuscating the fact that the agency has failed to meet its target reductions in total 

fatalities and fatality rates.

Roadside Inspections and Traffic Enforcement

Roadside inspections and commercial motor vehicle traffic enforcement are generally 

conducted by dedicated commercial vehicle safety inspectors employed by the states. The 

program consists of roadside inspections performed by approximately 10,000 qualified safety 

inspectors following the guidelines of the North American Standard, which was developed by 

the CVSA in cooperation with FMCSA. There are various levels of inspections for each 

component, which may include a vehicle component, a driver component, or both. An 

inspection is identified as a traffic enforcement event when at least one traffic violation is 

present in the inspection. The traffic enforcement program is based on 21 state or local traffic 

enforcement violations noted in conjunction with a roadside inspection. 15 Approximately 25% 

of inspections between 2003 and 2005 were traffic enforcement related.16 

Most roadside inspections by the states are conducted under the Motor Carrier Safety 

Assistance Program (MCSAP). MCSAP is a Federal grant program administered by FMCSA 

to provide funding to the states for commercial vehicle safety efforts. MCSAP was initially 

funded at $8 million in 1984. It increased substantially after the creation of FMSCA and grew 

to $188 million by FY 2006.17 The money is allocated by formula, and states are required to 

provide a match for the Federal funding, generally apportioned on an 80/20 basis. States 

determine their MCSAP priorities within allowable expenditures, and they may qualify for 

additional incentive grants or border funds. Some states elect to spend additional state funds 

beyond the MCSAP program to further oversee motor carrier safety. For example, while the 

total federal funding for MCSAP during FY 2005 was $169 million,18 the state of California 

spent $137 million on commercial motor vehicle programs in FY 2005.19

A roadside inspection occurs when an inspector conducts an examination on a 

commercial motor vehicle and driver to determine if they are in compliance with the 

FMCSRs and/or the hazardous materials regulations. Serious violations result in the 

15 http://ai.volpe.dot.gov/Help/Help.asp?#ri1 Volpe – A & I Program Measures, Roadside Inspections.

16 http://ai.volpe.dot.gov/ProgramMeasures/TE/TE.asp Volpe - A & I Program Measures, Traffic Enforcement.

17 DOT IG Report No. MH-2006-046 Significant Improvements in Motor Carrier Safety Program 

since 1999, but Loopholes for Repeat Violators Need Closing, Federal Motor Carrier Safety 

Administration, April 21, 2006.

18 http://www.fmcsa.dot.gov/safety-security/safety-initiatives/mcsap/mcsap-fy05.htm, FY 2005 MCSAP

Grant Allocations by State and Category.

19 California’s FY is July 1 through June 30. These figures do not include Motor Carrier Safety 

Assistance Program (MCSAP) grant funding.
Recommendations 97 Highway Accident Report

issuance of driver or vehicle out-of-service (OOS) orders. These violations must be 

corrected before the affected driver or vehicle can return to service. 

Approximately 73% of vehicles inspected are found to have at least one violation 

in roadside inspections. Further, 23% of vehicles have defects so serious that they are 

placed OOS and must be parked and repaired.20 The most common violation is out-ofadjustment brakes and defects in brake components, found in 57% of vehicles placed 

OOS. 21 Vehicles also may be placed OOS due to defects related to lights, tires, wheels, 

and cargo securement. 

Approximately 7% of drivers are placed OOS. The primary causes for placing 

drivers OOS are hours of service violations (57%), falsification of logs (12.4%), and 

drivers operating on suspended or disqualified licenses or without proper endorsements 

(8.5%).22 

Roadside Inspections (1996-2005)

0

500,000

1,000,000

1,500,000

2,000,000

2,500,000

3,000,000

3,500,000

199619971998

199920002001

2002

2003

2004

2005

Source: MCMIS

Although the number of inspections has increased from 1.35 million in 199623 to 

over 3 million inspections in 2005,24 the OOS rates have remained constant. Studies have 

shown that targeted inspections of higher-risk carriers and completely random inspections 

20 http://www.itsa.org/itsa/files/presentations/CVFMWirelessInspectionsLoftus.pps “Wireless Inspection 

Highlights” Jeff Lotus, FMCSA, March 2, 2006.

21 Roadcheck 2006, CVSA.

22 Ibid.

23 http://ops.fhwa.dot.gov/freight/freight_analysis/nat_freight_stats/docs/06factsfigures/table5_6.htm F

reight Facts and Figures, DOT.

24 MCMIS.
Recommendations 98 Highway Accident Report

result in similar OOS rates for drivers and vehicles.25 No matter the type or the number of 

inspections conducted in a given year, approximately one-quarter of commercial vehicles 

inspected have such serious violations that they must be parked and repaired before they 

can move. Such a high rate of safety violations is seen in no other mode of commercial 

transportation (air, rail, marine), nor would it be tolerated. The fact that this rate has 

remained high and constant over the last 10 years is significant. It means that the current 

penalty scheme is not sufficiently effective in ensuring that motor carriers comply with 

safety regulations. The sanctions imposed are considered the cost of doing business and 

thus suggest a tolerance level for violations of safety requirements.

Vehicle and Driver

Out-of-Service Rates 

0

5

10

15

20

25

30

19961997

1998

1999

2000

2001

2002

2003

2004

Source: MCMIS

Percentage

Driver Out-of-Service Rates

Vehicle Out-of-Service Rates

Compliance Reviews

Compliance reviews are the keystone of FMCSA’s safety program. According to 

the agency, the two main components of its safety monitoring system are compliance 

reviews and roadside inspections. As defined by FMCSA, a compliance review is an onsite examination of a motor carrier’s operations by a Federal safety investigator to 

determine a motor carrier’s safety fitness.26 A carrier cannot obtain a safety rating unless 

it undergoes a compliance review. Neither roadside inspections nor state safety audits 

similar to a compliance review result in a safety rating. There are over 900,000 active 

carriers,27 and the majority of carriers are unrated.

25 http://www.ai.fmcsa.dot.gov/CarrierResearchResults/PDFs/AdditionalReports/2003FleetSafety Surveys.pdf 

2003 National Truck Fleet and Bus Fleet Satety Surveys: Final Report.

26 Powerpoint, “What is a compliance review?” www.fmcsa.dot.gov/documents/training/comp_rev_mx_eng.

ppt - 2006-08-01.

27 MCMIS, Number of active carriers in 2005. 
Recommendations 99 Highway Accident Report

FMCSA prioritizes carriers for review based on their Safestat28 score or to follow 

up previous enforcement action. Additionally, compliance reviews may be initiated 

following a fatal accident or involvement in a major hazardous materials accident, as well 

as by complaints about carriers or at the carrier’s request. Generally, carriers subjected to 

compliance reviews are some of the worst carriers operating on the roadways. 

As identified in this accident report, only a fraction of the existing carriers received 

a compliance review in 2005; of the 910,866 carriers, just under 8,000, or less than 1%, 

were subjected to an on-site safety inspection. Of those, 5,022 carriers (63%) received a 

satisfactory rating, 2,138 carriers (27%) received a conditional rating, and 594 carriers 

(7%) received an unsatisfactory rating. 

In 2004, 19 months prior to the accident, Global received a satisfactory rating, despite 

numerous safety deficiencies cited, a fact that underscores the failure of compliance reviews to 

identify unsafe carriers. Although it had no maintenance program, deficiencies in its drug and 

alcohol program, and numerous driver violations, Global still received a satisfactory rating. 

(See attachment #1). Immediately following the bus fire, however, an FMCSA compliance 

review concluded that the carrier was not only unsatisfactory, but also an imminent hazard, and 

the agency ordered the company to cease operations. Although FMCSA predicts that its 

Comprehensive Safety Analysis of 2010 will address revisions to the carrier fitness rating 

system, the tragic consequences of this accident add urgency to the Safety Board’s Safety 

Recommendation H-99-6 to change the safety fitness rating methodology so that adverse 

vehicle and driver performance-based data alone are sufficient to garner an overall 

unsatisfactory rating. This recommendation was issued in 1999 following publication of 

NTSB’s Special Investigation Report on Selective Motorcoach Issues29 in which several 

motorcoach accidents were analyzed. It has been reiterated in this and other investigations,30

and it resides on our Most Wanted List of Transportation Safety Improvements.31

Only .0006 carriers of all carriers received a rating of unsatisfactory although the 

data indicate that 75% of roadside inspections result in at least one violation, with 

approximately 25% of vehicles and 7% of drivers having such serious violations that they 

must be placed OOS. The data further show that few carriers have their operating authority 

revoked. In addition, the Safety Board found during a recent investigation that a passenger 

carrier that had its interstate operating authority revoked continued to operate in interstate 

commerce undetected for several years. Although the carrier was subjected to at least one 

roadside inspection during that time, the lack of operating authority was not detected until 

after the company was scrutinized following its involvement in a fatal accident. 32

28 The SafeStat analysis program uses data from Federal and State sources, including roadside 

inspections, accident data, and enforcement actions for all carriers, to develop a safety fitness assessment of 

motor carrier.

29 NTSB/SIR-99/01.

30 NTSB/HAR-02/03 Collision Between Truck-Tractor Semitrailer and School Bus Near 

Mountainburg, Arkansas, on May 31, 2001.

31 http://www.ntsb.gov/Recs/mostwanted/highwayissues.htm.

32 NTSB Report Number HAR-06-03, Highway Accident Report: Multivehicle Collision on Interstate 

90, Hampshire-Marengo Toll Plaza, Near Hampshire, Illinois, October 1, 2003.
Recommendations 100 Highway Accident Report

Improvements to a carrier’s safety program and any enforcement action are 

predicated on the information documented in the compliance review. For years, regulators 

have been discussing ways to increase the number of compliance reviews, but while 

FMCSA’s budget has increased substantially since it was formed, there has been no 

commensurate increase in the number of the reviews completed. This issue was addressed 

by the House Appropriations Committee last year: “The Committee continues to be 

concerned that only a very small percentage of registered motor carriers undergo a safety 

compliance review each year.”33

While the agency has long promoted compliance reviews as the critical part of 

their mission, they often overstate the number of compliance reviews conducted each year. 

Testimony given by Administrator Sandberg in 2004 indicated that 11,000 compliance 

reviews were conducted that year.34 However data on FMCSA’s website show that less 

than 8,000 compliance reviews were conducted in 2004. A recent article in Bus & 

Motorcoach News stated that 12,000 compliance inspections are conducted annually35

when in reality, the agency has consistently fallen short of that goal. 

10,389

8,443

9,301

8,347

7,651 8,114

10,102

0

2,000

4,000

6,000

8,000

10,000

12,000

2000 2001 2002 2003 2004 2005 2006

Compliance Reviews 2000-2006

Source: 

2000 – 2001 (http://ai.fmcsa.dot.gov/ProgramMeasures/CR/NR/NSR/Report.asp?FC=C&RF=T&DP=P)

2002 – 2006 (http://ai.fmcsa.dot.gov/ProgramMeasures/CR//NR/NSR/Report.asp?FC=C&RF=T)

33 House Report 109-495 – Departments of Transportation, Treasury, and Housing and Urban 

Development, the Judiciary, District of Columbia, and Independent Agencies Appropriations Bill, 2007.

34 Administrator Annette Sandberg, Testimony before the Senate Commerce, Science and 

Transportation Committee, April 5, 2005.

35 “FMCSA Administrator vows to upgrade Fed’s coach safety oversight”, Bus & Motorcoach News, 

February 1, 2007.
Recommendations 101 Highway Accident Report

Large trucks represent about 4% of registered vehicles; however, they account for 

8% of the travel volume on our Nation’s highways. Approximately 12% of all the people 

killed in motor vehicle crashes die in crashes involving a large truck.36 There are 

approximately 9 million commercial truck and buses operating in the U.S. and over 

900,000 registered motor carriers. The truck vehicle miles traveled increase at a rate of 

approximately 2% each year.

FMCSA’s primary mission is to prevent commercial motor vehicle-related 

fatalities and injuries. It would be unfair to overlook the fact that FMCSA has made 

progress in certain areas: more enforcement cases have been opened and it has expanded 

its use of out-of-service orders consistent with authorities established in the MCSIA. In 

2004, 425 carriers received OOS orders for maintaining an unsatisfactory rating for more 

than 60 days, and 1,378 carriers received OOS orders for failing to pay a civil penalty after 

90 days. While commercial vehicles are over-represented in fatal accidents,37 fatalities 

have held steady in recent years although exposure is increasing due to higher vehicle 

miles traveled. However, while the FMCSA budget has almost increased by over 250% 

since the agency was established, many of FMCSA’s critical performance measures have 

remained essentially flat, including the number of annual fatalities in commercial motor 

vehicle crashes, the fatality rate, the driver and vehicle OOS rate in roadside inspections 

and the number of compliance reviews.

Conclusion

It is important to point out that for every unsafe motor carrier on the road, there are 

hundreds that take appropriate measures everyday to ensure the safety of their equipment 

and their drivers. Because the Safety Board’s role is to investigate accidents, we more often 

see those transportation providers (in all modes of transportation) whose approach to safety 

is something less than adequate. The circumstances of this tragic accident do not lead us to 

the conclusion that the motorcoach industry is unsafe or that motorcoaches are dangerous, 

because in reality, they have an excellent safety record, especially when compared to 

commercial trucks and passenger cars. However, it does serve to make us all aware that all 

motorcoach operations are not equal with respect to safety. Unfortunately, passengers place 

their trust in a motorcoach operator without any easy way to discern if the operator 

deserves that trust. They are entirely dependent on those charged with safety oversight to 

prevent them from entrusting themselves, or their loved ones, to the wrong carrier.

Unfortunately, this accident investigation revealed that a company that violates 

almost all of the safety rules can still slip through the cracks. FMCSA conducted a 

compliance review of Global’s operations in February, 2004 and issued the company a 

satisfactory rating, even though major deficiencies existed. In the following year, after the 

September, 2005 bus fire, the agency conducted a compliance review that documented 

36 http://www.dot.gov/bib2008/bibpart06fmcsa.htm, U.S. Department of Transportation, Budget in 

Brief – FY 2008, FMCSA.

37 Large trucks represent about four percent of registered vehicles; however, they account for eight 

percent of the travel volume on our Nation's highways. Approximately 12 percent of all the people killed in 

motor vehicle crashes die in crashes involving a large truck.
Recommendations 102 Highway Accident Report

many of the same safety violations but yielded a vastly different outcome. FMCSA 

declared that Global’s operations created an “imminent hazard” to public safety and issued 

an out-of-service order stating that Global’s pattern of FMCSR violations was consistent 

in nature and long in history. This accident is one of many in which the Safety Board has 

found inconsistencies based on a safety rating process that fails to remove the most unsafe 

carriers from the Nation’s highways.

FMCSA has the Herculean task of overseeing an industry where there are few 

barriers to entry and insufficient resources to conduct 100% oversight of every carrier, 

driver or truck. However, prior to this accident, there were multiple opportunities for 

intervention. FMCSA had the benefit of eight roadside inspections in the two years prior 

to this accident, four of which resulted in the drivers being placed out-of-service for 

serious violations of the Federal safety regulations. This 50% OOS rate identified Global 

as a high-risk carrier and prioritized them for inspection. The review conducted by the 

State of Texas in 2002 and the Federal compliance review conducted in 2004 documented 

numerous safety violations. Following the post-accident compliance review in 2005, 

FMCSA found that Global’s violations of the FMCSRs were “so widespread as to 

demonstrate a continuing and flagrant disregard for compliance” and that Global had a 

management philosophy “indifferent” to motor carrier safety. This disregard and 

indifference did not occur overnight -- it had existed for years. FMCSA has advised the 

Safety Board for over a decade that the rating system is going to be revised to better 

identify unsafe carriers. Recently, these promises were made part of FMCSA’s 

Comprehensive Safety Analysis 2010. But right now, this accident proves that the agency 

charged with safety oversight of our motor carriers is not getting even the worst of the 

worst carriers off the roads. The system is broken, and the traveling public can’t afford to 

wait until 2010 to fix it.

Deborah A. P. Hersman

February 28, 2007
Exhibit from Panel Six – Wilmer Public Hearing 

VIOLATIONS NOTED ON REVIEWS

Educational Review

4/10/2002

Pre-Fire Compliance 

Review 2/12/2004 

Post-Fire Compliance Review 10/

Part 382, Drug & Alcohol 

Program

• No drug/alcohol testing

program ACUTE 

Part 382, Drug & Alcohol 

Program

• Failing to provide drivers 

with drug/alcohol policies 

• Failure to have persons 

trained for reasonable 

suspicion 

Part 382, Drug & Alcohol Program

• Using driver w/o pre-employment drug test 

• Failing to provide drivers with drug/alcohol 

• Failure to have drug/alcohol random testing 

• Failure to conduct post accident drug/alcoh

• Failure to have persons trained for reasona

Part 391, Driver Qualification 

Files

• No driver background 

investigation 

• No driver employment 

application

• No driver record inquiry 

CRITICAL

Part 391, Driver Qualification 

Files

• Failing to maintain a

copy of response from

each State agency 

• Failing to maintain a note 

relating to the driver’s 

annual record check

• Failing to maintain a

driver’s medical examiner certificate 

Part 391, Driver Qualification Files 

• Non-English speaking driver 

• Using driver w/o valid license 

• Using driver w/o complete employment app

• Failure to maintain a Driver Qualification Fi

• No driver record inquiry CRITICAL 

• Failing to maintain a note relating to the dri

record check

• Failure to maintain list of motor vehicle viol

Part 395, Hours of Service 

• Failure to require driver 

to make a record of duty 

status1 (log) CRITICAL 

Part 395, Hours of Service 

• False logs 

Part 395, Hours of Service 

• Permit violation 10 hour rule 

• Permit violation of 15 hour rule 

• Failure to require driver to make a record o

1 49 CFR Part 395.8 identifies the driver’s Record of Duty Status (RODS). The motor carrier industry and public commonly use the word “log” in lieu of th

Duty Status or RODS. The term log is used in this report because of its common usage and familiarity to the public and the motor carrier industry. 
• Failure to require form

and manner on driver 

log

• False log CRITICAL 

Part 396, Vehicle 

• Failure to maintain 

vehicle inspection and 

maintenance records 

• Failure to maintain 

evidence of brake 

inspector’s qualifications 

Part 396, Vehicle 

Failure to have a schedule for 

vehicle inspection and 

maintenance

Part 396, Vehicle 

• Failure to maintain vehicle inspect vehicles 

• Fail to inspect emergency exits 

• Failure to require driver inspection reports 

• Operate CMV w/o Periodic Inspection CRIT

Factor Rating Acute Critical Factor Rating Acute Critical Factor Rating Acute Critical 

Factor 1: S 0 0 

Factor 2: U 1 1 

Factor 3: U 0 2

Factor 4: S 0 0 

Factor 5: N 0 0 

Factor 6: S - - 

Factor 1: S 0 

Factor 2: S 0 0 

Factor 3: S 0 0 

Factor 4: S 0 0 

Factor 5: N 0 0 

Factor 6: S 0 0 

Factor 1: S 0 0 Factor 2: U 1 2

Factor 3: U 0 2

Factor 4: U 0 2

Factor 5: N 0 0 

Factor 6: S - - 

SAFETY RATNG SAFETY RATING SAFETY RATING 

Unsatisfactory Satisfactory Unsatisfactory 

Factor 1: General = Parts 387 & 390 

Factor 2: Driver = Parts 382, 383 & 391 

Factor 3: Operational = Parts 392 & 395 

Factor 4: Vehicle = Parts 393 & 396

Factor 5: Haz Mat = Parts 397, 171, 177 & 180 

Factor 6: Accident Factor = Recordable Rate

CALCULATION FORMU

Unsatisfactory Conditional Ov

0 2 or fewer S0 3 or more C1 2 or fewer C1 3 or more Un2 0 or more Un
Recommendations 105 Highway Accident Report

Member Kathryn O’Leary Higgins, Concurring and dissenting in part:

I concur with nearly all of this important report on our investigation into the tragic 

fire aboard a motor coach evacuating 44 assisted living residents and staff out of the forecast 

path of Hurricane Rita in September 2005. Twenty-three passengers were killed in that fire.

Probable Cause:

Naming the Federal Motor Carrier Safety Administration in the probable cause 

statement was justified because of the agency’s delay in making changes that are critical to 

improving highway safety. Eight years ago the Safety Board first recommended 

significant and substantive change to improve the safety of motor carrier operations: 

specifically, recommendation H-99-6, was issued in February 1999, was reiterated in 2002 

and was added to the Most Wanted List in 2000 and is reiterated again in this report. That 

recommendation would require a change in the safety fitness methodology so that adverse 

vehicle or driver performance-based data alone would be sufficient to result in an overall 

unsatisfactory rating for a carrier. The status of that recommendation currently is “openunacceptable response.” I believe that this accident could have been prevented if FMCSA 

had acted to implement this recommendation when it was first proposed. Under the 

compliance standard recommended by the Safety Board, Global Limo would have been 

rated unsatisfactory in pre-accident inspections based on the issues identified with both 

drivers and vehicle maintenance.

The State of Texas conducted an educational review of the operator in 2002 and found 

several serious issues. That initial review was triggered by customer complaints. Information 

from that review was provided to FMCSA. The findings from that review were so serious that 

the carrier would have been put out of service if it had been a compliance review rather than 

an education review. At that time Texas did not have the authority to place vehicles out of 

service. Texas gained that authority in 2004, prior to the fatal accident. Compliance 

monitoring and a follow-up review was recommended in 2002 but not conducted by the state. 

At the public hearing the state acknowledged its earlier recommendations but offered no 

explanation as to why the recommended reviews were not conducted.

FMCSA did not conduct a compliance review for almost two years after the initial 

Texas review. This was the first compliance review of Global Limo since the company 

began operations in 1980. The company was given a satisfactory rating because the 

vehicles were not inspected and not all the drivers were interviewed, nor was that required 

under the FMCSA compliance review system. That same system is still in place today.

In my opinion, the lack of rigorous oversight, inspection and enforcement at both 

the Federal and state levels contributed to this accident. Only after the Wilmer accident did 

FMCSA place the carrier out of service, citing violations that were virtually identical to the 

violations found in the earlier review. This time the vehicles were inspected. I believe that 

both the State of Texas and FMCSA should be cited as contributing to this accident. Both 

failed in their responsibility to exercise oversight and enforce the regulations.
Recommendations 106 Highway Accident Report

To improve safety on our highways, the current system needs an immediate 

overhaul. FMCSA has promised to make changes as part of their 2010 initiative. Each 

year there are over 5,000 fatal accidents involving federally registered motor carriers. Can 

we really afford to wait another three years and perhaps longer to tighten the rules that will 

take unsafe vehicles and drivers off the road? I am pleased that the Board voted to issue 

an Urgent Recommendation that asks FMCSA to issue an interim rule “to include all 

Federal Motor Carrier Safety Regulations in the current compliance review process so that 

all violations of regulations are reflected in the calculation of a carrier’s final rating”.

With only 1,000 employees nationwide, FMCSA must leverage its resources more 

effectively by partnering with the States to ensure that the rules are being enforced. More 

than 910,000 motor carriers were registered in the United States in 2005. FMCSA 

conducted compliance reviews on almost 8,100 of those carriers. In other words, less than 

1% of carriers undergo a compliance review each year. Even the IRS has a higher audit rate.

As a result of those reviews, 61,924 violations were discovered yet the vast 

majority of those violations – 85.7% (53,064) – were not used to develop a safety rating of 

a carrier. It is not clear whether it is the design or the implementation of the safety 

program that results in this unsettling statistic. But, it is clear that change is needed. 

One approach is to require the states to take more responsibility for ensuring 

compliance. Approximately half the states are conducting compliance reviews for intrastate 

carriers. A similar number of states have the authority to put intrastate carriers out of 

service. Most of the carriers reviewed by states operate under both intra and interstate 

authority. We need a uniform system across the country. All states should have the authority 

to both conduct compliance reviews, using, at a minimum, FMCSA criteria, and put carriers 

out of service. If an intrastate carrier is taken out of service as a result of a state review, that 

carrier should no longer be able to operate across state lines. I believe the role of the states 

can and should be expanded in the name of making our roads and highways safer. The 

federal role should be to set uniform standards, develop model enforcement and compliance 

programs, provide technical assistance to states and operators, maintain the database and 

ensure state compliance with federal requirements. The current federal enforcement scheme 

does not raise the safety bar. States refer interstate cases to FMCSA with its regulatory 

scheme that has been compared to Swiss cheese. We recently celebrated the 50th anniversary 

of the interstate highway system. This system has connected this country from coast to coast 

and has made an enormous difference in the way business is conducted. Many, if not most, 

of the goods purchased on the inter-net are delivered via the interstate. Those roads were 

built with a combination of state and federal funds but to uniform standards. Why shouldn’t 

the rules that enforce safety on those roads be uniform, as well?

Bus Brokers

I firmly believe that BusBank, the broker that linked Global Limo and Sunrise, 

should be cited as a contributing to this accident. BusBank promotes the safety and 

qualifications of its operators on its website. BusBank advertises a 5-Star Guarantee, and the 

first star is safety. Unfortunately, as this accident revealed, that guarantee is hollow because 

there is no supporting qualification program behind that promised guarantee. If BusBank 
Recommendations 107 Highway Accident Report

had gone behind its website promises to investigate, Global Limo Inc. would have failed 

several of the criteria that BusBank said it used to qualify the company for referral: there 

were no pre-drug and alcohol testing of the driver; no driver training program: the accident 

driver was not properly licensed in the State of Texas and did not have a U.S. medical 

certificate, as required and could not communicate with the passengers because he did not 

speak English; the accident bus was not properly registered; and the bus was being operated 

in violation of the contract signed by the Canadian owners and was not maintained. 

Bus Bank, contrary to their claims, did not put Global Limo through a “due 

diligence” process, did not know the operator, and had no ongoing qualifications process 

for this operator. Global Limo did not even return the qualifications questionnaire sent to 

them by the BusBank. Without further inquiry, BusBank added Global Limo to its list of 

operators. The form does not ask for any of the other safety information mentioned above, 

nor does it ask for information from any previous inspections or reviews that might have 

been done on the vehicles, drivers or operators.

A consumer, such as Sunrise Assisted Living, might well be swayed by the claims 

of independent safety oversight by a third party claiming to be a leader in the bus industry. 

And the stopgap, the Federal oversight on which BusBank claimed to rely and on which 

the American public rely also failed. When asked about their safety assurances, BusBank 

said they relied on the FMCSA website and the satisfactory rating given to Global Limo. 

They admitted that they did not look behind the rating to better understand issues that may 

have been identified in the compliance review. They did not seek any information from 

the State of Texas on Global’s operations. 

BusBank’s claims misled customers because BusBank did not look behind the 

federal rating did not seek information from the state, did not ask for relevant safety 

information from Global Limo nor was there any independent review of Global Limo. 

BusBank is in the business of connecting the public with bus transportation, claiming to be 

experts in their field. They ask the public to rely on their 5- Star Guarantee where “safety 

is first.” Yet, in our public hearing on this accident, BusBank testified that they are not 

“safety experts” but they guarantee safety in their promotions. 

FMCSA has some limited statutory authority to protect consumers by regulating 

household goods brokers. FMCSA does not have similar authority over brokers who 

connect paying passengers and bus companies. The Department of Transportation is 

specifically prohibited from regulating bus brokers. The traveling public is relying on the 

claims of BusBank and other companies when they or their representatives contract to 

charter a bus. The inter-net has made it much easier for individuals and companies to 

become transportation brokers. How is the public supposed to verify claims made by these 

brokers without some independent way to assess them? We don’t even know how many 

bus brokers there are because they aren’t required to register, as those who broker the 

transport of household goods are. Why have we placed a higher value on the transport of 

goods than the transport of people? I believe the Department of Transportation should seek 

repeal of the regulatory prohibition and develop standards that to require the registration of 

bus brokers and compliance with standards to protect and promote public safety. 
Recommendations 108 Highway Accident Report

NTSB staff has agreed to look into the issue of Federal jurisdiction to protect 

traveling consumers against deceptive and false advertising and to return to the Board 

with a recommended approach to highlight this issue for Federal policymakers. The 

Chairman has sent a letter to the Federal Trade Commission asking them to investigate 

BusBank’s practices. While that is a good start, I believe we should go further. We should 

take action to help policy makers understand this issue in order to determine the best 

approach to deter misrepresentation by brokers.

Reporting of Bus Fires:

The public hearing on this accident documented that adequate data on bus fires in 

this country is lacking because there is no requirement that bus fires be reported. Therefore, 

bus fire incidents are not captured in a consistent way in any national database. As a result 

of our investigation and the public hearing, we learned that the incidence of bus fires is much 

higher than had been previously understood. One witness testified that as many as five bus 

fires per week may occur in this country. The causes of bus fires are also varied and can start 

in the engine, in the electrical system, in the wheel wells and in the cooling system.

While I am encouraged by FMCSA’s contract with the Volpe Center to gather data 

and set up a system to analyze the data that currently exists, I continue to be concerned 

that the Volpe study is examining data from previous fires, captured from a variety of 

sources. While that study may be useful in establishing a baseline, it does not appear to be 

designed to capture information on future bus fires. For that reason we have made a 

recommendation to FMCSA to continue to gather and evaluate information on the causes, 

frequency, and severity of bus and motor coach fires.

I want to emphasize the importance of this issue. I urge immediate attention to this 

recommendation because we must begin to document these events and understand the 

source of the fires as well as their frequency, and the impact on passengers and the 

vehicles. Unless we accurately document this significant safety challenge we will not 

understand the dimensions of the bus fire problem, nor will we know what steps are most 

effective in mitigating the problem and will have no way of documenting progress in 

reducing the number and severity of such incidents.

Fire Detection and Suppression:

During our hearing we heard that bus fires are started by more than one source. We 

also learned that the source of the fire does not seem to affect the intensity of the fire 

because of the new materials and more powerful engines found on modern motor coaches. 

For this reason we asked the FMCSA to move expeditiously to evaluate the best way to 

detect fires that begin in wheel wells as well as fires ignited by other sources and then 

develop standards to be used by industry for purchasing and installing such detection 

equipment. As part of the revisions adopted at the Board Meeting and circulated 

afterwards for Board Member approval, a new recommendation to the National Highway 

Traffic Safety Administration (NHTSA) was added. The recommendation asks NHTSA 

to “evaluate the need for a Federal Motor Vehicle Safety Standard that would require 

installation of fire detection and suppression systems on motor coaches”. While I concur 

with the recommendation, I believe clarification of that recommendation is in order.
Recommendations 109 Highway Accident Report

During our investigation of the Wilmer accident and a 2-day public hearing that 

followed, we learned that bus fires are an alarming and under-reported safety issue in this 

country. We also learned that there are multiple sources for these fires (engines, batteries, 

electrical systems, heaters, and tires/wheel and braking components). Our report and 

findings, as currently written, do not adequately address actions that should be taken with 

regard to fires that begin in a location other than the tire or wheel well. Our report also does 

not mention the important work done by staff to investigate and document other bus fires.

I am concerned that the report and recommendation to NHTSA, as currently 

drafted, do not provide adequate guidance to NHTSA concerning the rationale for this 

additional recommendation. I would like to place that recommendation in context in light 

of my extensive personal involvement in the hearing that supported the investigation.

If I were drafting this recommendation, I would ask NHTSA to “Evaluate the need 

for a Federal Motor Vehicle Safety Standard that would require installation of fire 

detection and suppression systems on motor coaches, taking into account the multiple causes 

and sources of bus fires and the technology available to detect and suppress these fires.” I believe this 

additional language offers better guidance to NHTSA as to this Member’s intent in 

proposing this additional recommendation.

I also believe that the report would be strengthened if it included a finding 

reflecting the need for this recommendation. Research results, information provided 

separately to the Board and public testimony from the hearing confirm that bus fires occur 

more frequently than previously understood and are ignited in a number of different ways. 

Unfortunately, there is currently no federal standard requiring detection or suppression 

equipment on busses or motor coaches. An energetic response to this situation by NHTSA 

could significantly improve this situation.

Evacuation of citizens with special needs:

In this accident, 23 people died, and 21 escaped the burning bus with a variety of 

injuries. We have learned many things as result of this accident, including how 

ill-prepared we were to evacuate and ensure the safety of travelers with special needs. 

With the experience of Hurricane Katrina fresh in our minds, there was extraordinary 

pressure on transportation resources in advance of Hurricane Rita. Local, state and federal 

agencies worked, but not always in concert, to evacuate those in the path of another 

dangerous natural event. In an effort to get as many large trucks and buses on the road to 

provide disaster assistance before and after Hurricane Rita, the governor of Texas declared 

a state of emergency and waived certain regulatory requirements. While it has been 

claimed that safety requirements were not waived, this declaration process does in fact 

result in the temporary waiver of some federal safety requirements for drivers and 

companies providing direct relief efforts in a declared emergency. The only federal 

requirements that may not be waived are those related to commercial driver licenses, drug 

and alcohol testing, and insurance responsibility. I was also told that the waivers do not 

exempt operators from maintaining their busses. Press accounts have suggested that the 

operator of Global Limo could not be charged with all of the violations he committed 

because of the Evacuation Order and the subsequent waivers. As a result, his sentence 
Recommendations 110 Highway Accident Report

was much lighter than it might have been. I am concerned that in the interest of taking 

people out of harms way we may inadvertently be “waiving safety” and creating the 

potential for more harm. I hope that is not the case but this accident has raised that issue.

I understand that these were terrible circumstances and extraordinary things were 

done to evacuate people out of the path of Hurricane Rita. And I am pleased that 

governments at all levels have reviewed their performance during that time. Many reports 

were produced that raised and changed awareness of the challenges and solutions for largescale emergency evacuations. A particularly troubling aspect of these reports is how ill 

prepared we are as a nation to evacuate those who are most vulnerable, particularly the 

elderly, disabled and those in hospitals and nursing homes. Only a few states currently have 

acceptable evacuation plans. In a post 9/11 world that is both unfortunate and unacceptable.

As a result of these reviews the White House designated the Department of 

Transportation as the lead Federal agency to coordinate and oversee transportation 

planning for emergency evacuations and assist state and local jurisdictions when help is 

needed. I hope those charged with that responsibility will review this report, the records 

contained in the public docket and the transcript of the public hearing.

This accident must be considered in the context of the events that were occurring 

at the time. While the evacuation of persons with special needs does not come under the 

purview of the NTSB, this accident cannot be understood without looking at these issues. 

As the Probable Cause makes clear, the loss of life was exacerbated because of the frailty 

of the passengers. Motor coaches were used for this evacuation and will be used again 

should a similar emergency arise. For that reason alone our recommendations must be 

given every consideration and implemented as quickly as possible. Our findings on 

oversight and compliance, on survival factors, bus design and maintenance, fire detection 

and suppression, to list a few will hopefully move policy makers to act. None of us want 

to see this accident repeated and the only way to insure that doesn’t happen is to act on the 

changes proposed in this report. 

Kathryn O’Leary Higgins

April 20, 2007
111 Highway Accident Report

Appendix A

Investigation and Public Hearing

Investigation

The National Transportation Safety Board was notified of the Wilmer, Texas, 

accident on September 23, 2005. An investigative team was dispatched with members 

from the Washington, D.C.; Denver, Colorado; Gardena, California; Arlington, Texas; and 

Parsippany, New Jersey, offices. Ellen Engleman Conners was the Member on scene. 

Groups were established to investigate human performance; motor carrier operations; 

hazardous materials; fire; and highway, vehicle, and survival factors.

Participating in the investigation were representatives of the Federal Motor Carrier 

Safety Administration (FMCSA), the Pipeline and Hazardous Materials Safety 

Administration (PHMSA), the State of Texas Department of Transportation, the State of 

Texas Department of Public Safety (TxDPS), the Dallas County Sheriff’s Department, 

Motor Coach Industries, Inc. (MCI), ArvinMeritor, Inc., and Bridgestone Americas 

Holding, Inc.

No depositions were taken.

Public Hearing

The Safety Board held a public hearing on this accident on August 8–9, 2006, in 

Washington, D.C. Board Member Kathryn O’Leary Higgins presided over the hearing, 

and Member Deborah A. P. Hersman participated. The issues presented at the hearing 

were the scope of bus fires in the United States, Government oversight of motorcoach 

operators and bus brokers, commercial vehicle inspections, evacuation of motorcoaches, 

and planning for the transportation of passengers with special needs during emergency 

evacuations.

Safety Board investigators were members of the technical panel. Parties to the 

public hearing included the FMCSA, the National Highway Traffic Safety Administration, 

the TxDPS, the Commercial Vehicle Safety Alliance, MCI, ArvinMeritor, Inc., 

Bridgestone Americas Holding, Inc., Sunrise Senior Living Services, Inc., the American 

Bus Association, and the United Motorcoach Association.
112 Highway Accident Report

Appendix B

Global Limo Inc. Federal Motor Carrier Safety Administration 

Compliance Reviews

February 2004 Compliance Review Violations

382.601(a) Violation

• Failing to provide educational materials explaining the requirements of Part 

382 and employer’s policies.

382.603 Violation

• Failing to ensure persons designated to determine that drivers undergo 

reasonable suspicion testing receive 60 minutes training for alcohol and/or 60 

minutes training for controlled substances.

391.25(c)(1) Violation

• Failing to maintain a copy of the response from each State agency in the driver 

qualification file.

391.51(b)(5) Violation

• Failing to maintain a note relating to the annual review of the driver’s driving 

record as required by 3941.25(c)(2).

391.63(a) Violation

• Failing to maintain medical examiner’s certificate in driver’s qualification file.

395.8(e) Violation

• False reports of records of duty status.

396.3(b)(2) Violation

• Failing to have a means of indicating the nature and due date of the various 

inspection and maintenance operations to be performed.
Appendix B 113 Highway Accident Report

February 2004 Compliance Review Recommendations

This report contains citations of regulations that are deemed serious in nature and

could result in penalties against your company and/or drivers.

• Review with your drivers periodically the procedures for doing pretrip and

posttrip inspections. Ensure that safety defects reported on driver vehicle

inspection reports (DVIRs) are repaired before the vehicle is re-dispatched.

Require drivers to prepare DVIRs on a daily basis. Keep them on file for 90

days.

• Ensure that all vehicles are systemically repaired and maintained. Establish a

complete file for each vehicle and record all inspection, maintenance, and

repair operations performed. Consider keeping records pertaining to each

individual unit in its own folder.

• Periodically review the maintenance and inspection records for all leased

vehicles as required by Part 396 of the FMCSRs. Keep a record to document

these reviews and notify the owner of any violations detected.

• Ensure that all drivers are fully and properly qualified before operating in

interstate commerce. Maintain a complete file, as required, for each driver,

documenting the qualification process.

• Ensure that all drivers’ records of duty status (logs) are accurate. Check them

against “supporting documents” to verify accuracy. Prohibit falsification of

logs by any driver. Review rules on supporting documents. Take appropriate

action against drivers who falsify logs.

• Establish a system to control passenger-carrying drivers’ hours of service. Do

not dispatch drivers who do not have adequate hours available to complete

assigned trips legally. Do not allow drivers to exceed the 10-, 15-, and 60/70-

hour limits.

October 2005 (Post-Fire) Compliance Review Violations

382.301(a) Violation

• Using a driver before the motor carrier has received a negative preemployment

controlled substance test result.

382.303(a) Violation

• Failing to conduct postaccident alcohol testing for each surviving driver.

382.303(b) Violation

• Failing to conduct postaccident controlled substances testing for each

surviving driver.
Appendix B 114 Highway Accident Report

382.305(i)(1) Violation

• Failing to use a scientifically valid method to select drivers for random testing.

382.305(i)(2) Violation

• Failing to ensure that each driver selected for random alcohol and controlled 

substance testing has an equal chance of being selected each time selections 

are made.

382.401(c)(6) Violation

• Failing to maintain semiannual laboratory statistical summaries of urinalysis 

required by 40.29(g)(6).

382.601(a) Violation

• Failing to provide education materials explaining requirements of Part 382 and 

employer’s policies.

382.603 Violation

• Failing to ensure persons designated to determine that drivers undergo 

reasonable suspicion testing receive 60 minutes training for alcohol and/or 60 

minutes training for controlled substances.

391.11(b)(2) (Primary) 391.11(a) (Secondary) Violation

• Using a driver unable to read and/or speak the English language.

391.11(b)(5) (Primary) 391.11(a) (Secondary) Violation

• Using a driver without a currently valid motor vehicle operator’s license or permit.

391.21(a) Violation

• Using a driver who has not completed and furnished an employment 

application.

391.51(a) Violation

• Failing to maintain driver’s qualification file on each driver employed.

391.51(b)(2) Violation

• Failing to maintain inquiries into driver’s driving record in driver’s 

qualification file.
Appendix B 115 Highway Accident Report

391.51(b)(5) Violation

• Failing to maintain a note relating to annual review of the driver’s driving 

record, as required by 3914.25(c)(2).

391.51(b)(6) Violation

• Failing to maintain a list or certificate relating to violations of motor vehicle 

laws and ordinances required by 391.27.

395.3(a)(1) Violation

• Requiring or permitting a driver to drive more than 10 hours.

395.3(a)(2) Violation

• Requiring or permitting driver to drive after having been on duty 15 hours.

395.8(a) Violation

• Failing to require driver to make a record of duty status.

395.8(e) Violation

• False reports of records of duty status.

396.3(a)(1) Violation

• Failing to inspect and maintain vehicle to ensure safe and proper operating 

condition.

396.3(a)(2) Violation

• Failing to inspect pushout windows, emergency doors, and emergency marking 

lights in buses at least every 90 days.

391.11(a) Violation

• Failing to require driver to prepare DVIRs.

396.17 Violation

• Using a commercial motor vehicle not periodically inspected.
Appendix B 116 Highway Accident Report

October 2005 (Postfire) Compliance Review Recommendations

This report contains citations of regulations that are deemed serious in nature and 

could result in penalties against your company and/or drivers.

• Review with your drivers periodically the procedures for doing pretrip and 

posttrip inspections. Ensure that safety defects reported by drivers on their 

DVIRs are repaired before the vehicle is redispatched. Require drivers to 

prepare DVIRs on a daily basis. Keep them on file for 90 days.

• Ensure that the persons or entities that perform preventative maintenance 

inspections on your equipment are abiding by agreed time or mileage intervals. 

Ensure that records are kept of such periodic preventative maintenance 

inspections. Take corrective action if schedules are not being adhered to.

• Require all drivers to prepare a written inspection report for each day a vehicle 

is operated. Ensure that each report is signed by the driver, certified, and 

reviewed if defects are reported, and then kept in the vehicle for a day.

• Keep all driver DVIRs signed, certified, and reviewed, as required, on file for 

at least 90 days.

• Ensure that all vehicles are systemically repaired and maintained. Establish a 

complete file for each vehicle, recording all repair, maintenance and inspection 

operations performed.

• Establish a system to control drivers’ hours of service. Do not dispatch drivers 

who do not have adequate hours available to complete assigned trips legally. 

Do not allow drivers to exceed the 10-, 15-, and 60/70-hour limits.

• Ensure that all drivers’ records of duty status (logs) are accurate. Check them 

against “supporting documents” to verify accuracy. Prohibit falsification of 

logs by any driver. Review rules on supporting documents. Take appropriate 

action against drivers who falsify logs.

• Require all drivers to prepare complete and accurate records of duty status for 

each day and to submit them within 13 days. Maintain all duty status records 

on file, with all supporting documents, for at least 6 months.

• U.S. Department of Transportation (DOT) drug testing rules require that 

employers test for marijuana, cocaine, opiates, amphetamines, and 

phencyclidine, 49 CFR Parts 40 and 382.

• Ensure that all drivers subject to preemployment, random, reasonable cause, 

postaccident, return to duty, and/or followup controlled substance testing are 

tested as required by 49 CFR Parts 40 and 382.

• Ensure that all drivers are fully and properly qualified before operating in 

interstate commerce. Maintain a complete file, as required, for each driver, 

documenting the qualification process.

• Ensure that drivers provide a 10-year employment history on their employment 

applications.
117 Highway Accident Report

Appendix C

Federal Motor Carrier Safety Administration Safety Program

Compliance Review

The safety fitness rating begins with a compliance review conducted by the

Federal Motor Carrier Safety Administration (FMCSA), as specified in 49 Code of

Federal Regulations (CFR) Part 385, appendix A. The FMCSA applies six factors

(general, driver, operational, vehicle, hazardous materials [HM], and accident rate [see

table C-1]) to rate a carrier’s compliance with the Federal Motor Carrier Safety

Regulations (FMCSRs). A carrier may be selected for a compliance review if it is

identified as a high-risk carrier because of (1) a Safety Status Measurement System

(SafeStat) score,1

 (2) a complaint against the company, (3) an enforcement followup, (4)

involvement in a fatal accident, or (5) involvement in a major HM accident. In addition, a

carrier may be selected as a result of a U.S. Department of Transportation (DOT) Office of

Inspector General request, a congressional inquiry, or a carrier’s request.

For factor 4, vehicle, the carrier’s out-of-service (OOS) rate is determined by the

number of vehicles placed out of service in relation to the number of vehicles inspected

roadside. The number of roadside vehicle inspections depends on the number of vehicles in a

carrier’s fleet. Only the most recent (the past 12 months in chronological order) roadside

inspections are applied for the OOS calculation.2 If a carrier’s OOS rate exceeds 34 percent

and the carrier has a pattern of critical or acute violations or both, the rating is unsatisfactory.

If the carrier’s OOS rate exceeds 34 percent, but the carrier does not have a pattern of

violations, the rating is conditional. If the carrier’s OOS rate is less than 34 percent, but the

carrier has a pattern of critical or acute vehicle violations or both, the rating is conditional.

Otherwise, the carrier receives a satisfactory rating for an OOS rate under 34 percent.

Table C-1. Factors for FMCSA safety compliance.

1 The SafeStat analysis program uses data from Federal and State sources, including roadside

inspections, accident data, and enforcement actions for all carriers, to develop a safety fitness assessment.

2 For example, a motor carrier with 20 vehicles would require a minimum of 5 vehicle inspections, and

the 5 most recent inspections for the past 12 months or since the last compliance review would be used to

calculate the carrier’s OOS rate. These inspections may have been conducted during a roadside inspection or

at the carrier’s terminal.

Factor Applicable FMCSRs and other criteria

1 – General Parts 387 and 390

2 – Driver Parts 382, 383, and 391

3 – Operational Parts 392 and 395

4 – Vehicle Parts 393 and 396 and OOS rate

5 – Hazardous materials Parts 107, 171, 173, 177, 180, and 397

6 – Accident rate Recordable accident rate
Appendix C 118 Highway Accident Report

Factor 6, accident rate, is rated either “satisfactory” or “unsatisfactory”; a 

conditional rating is not given. The recordable accident rate is calculated by multiplying 

the number of interstate, reportable accidents for the 12 months prior to the compliance 

review by 1 million and dividing that number by the fleet’s total interstate miles. If a 

carrier’s accident rate exceeds 1.5 million miles for a company that operates over a 100-

mile radius or 1.7 million miles for a company that operates in less than a 100-mile radius, 

an unsatisfactory rating is given. A calculated number under these rates results in the 

company receiving a satisfactory rating for this factor.

The rating table establishes the motor carrier’s overall final safety rating, also 

designated “satisfactory,” “conditional,” or “unsatisfactory,” as defined below:

• Satisfactory rating: The carrier is determined to have sufficient safety 

management controls in place to meet the safety fitness standards of the 

FMCSRs.

• Conditional rating: The carrier does not have sufficient safety management 

controls in place and could be in violation of the safety fitness standards.

• Unsatisfactory rating: The carrier does not have adequate safety management 

controls in place and has violated the safety fitness standards.

When the FMCSA issues a final3 unsatisfactory safety rating to a carrier, the owner 

or operator is deemed unfit to operate.4 Owners or operators of commercial vehicles that 

are designed or used to transport passengers and that have been declared unfit may not 

operate in interstate commerce beginning on the 46th day following the date of such safety 

fitness determination and may not reestablish interstate operations until they become fit 

for such transportation.

3 A safety rating will be issued to a motor carrier within 30 days of the completion of a compliance review. 

A proposed safety rating of unsatisfactory is a notice to the motor carrier that the FMCSA has made a 

preliminary determination that it is “unfit” to continue operating in interstate commerce and that the prohibitions 

in 49 CFR 385.13 will be imposed after 45 or 60 days, if necessary safety improvements are not made.

4 According to 49 CFR 385.13(a), an owner or operator receiving notice of a proposed unsatisfactory 

safety rating from the FMCSA must improve that rating to conditional or satisfactory within 45 days of the 

date of the notice. Owners or operators who fail to improve their ratings within this 45-day period are 

prohibited from operating in interstate commerce beginning on the 46th day following the date of the rating 

notice. Owners or operators are “fit” to operate when the FMCSA issues a final conditional or satisfactory 

safety rating.
119 Highway Accident Report

Appendix D

Excerpts From Federal Motor Carrier Safety Regulations

49 Code of Federal Regulations (CFR) Parts 390–396

393.205 Wheels

(a) Wheels and rims shall not be cracked or broken.

(b) Stud or bolt holes on the wheels shall not be elongated (out of round).

(c) Nuts or bolts shall not be missing or loose.

396.5 Lubrication

Every motor carrier shall ensure that each motor vehicle subject to its control is

(a) properly lubricated; and

(b) free of oil and grease leaks.

396.7 Unsafe Operations Forbidden

(a) General: A motor vehicle shall not be operated in such a condition as to likely 

cause an accident or a breakdown of the vehicle.

(b) Exemption: Any motor vehicle discovered to be in an unsafe condition while 

being operated on the highway may be continued in operation only to the nearest 

place where repairs can safely be effected. Such operation shall be conducted only 

if it is less hazardous to the public than to permit the vehicle to remain on the 

highway.

See <www.fmcsa.dot.gov>, December 15, 2006.

Appendix B, 49 CFR Part 385, Explanation of Safety Rating Process

Part II. Converting Compliance Review Information Into a Safety Rating

(a) The FMCSA gathers information through an in-depth examination of the motor 

carrier’s compliance with identified “acute” or “critical” regulations of the Federal 

Motor Carrier Safety Regulations (FMCSRs) and Hazardous Materials 

Regulations (HMRs).
Appendix D 120 Highway Accident Report

(b) Acute regulations are those identified as such where noncompliance is so 

severe as to require immediate corrective actions by a motor carrier regardless of 

the overall safety posture of the motor carrier. An example of an acute regulation is 

§383.37(b), allowing, requiring, permitting, or authorizing an employee with more 

than one commercial driver’s license (CDL) to operate a commercial motor 

vehicle. Noncompliance with §383.37(b) is usually discovered when the motor 

carrier’s driver qualification file reflects that the motor carrier had knowledge of a 

driver with more than one CDL, and still permitted the driver to operate a 

commercial motor vehicle. If the motor carrier did not have such knowledge or 

could not reasonably be expected to have such knowledge, then a violation would 

not be cited.

(c) Critical regulations are those identified as such where noncompliance relates to 

management and/or operational controls. These are indicative of breakdowns in a 

carrier’s management controls. An example of a critical regulation is §395.3(a)(1), 

requiring or permitting a property-carrying commercial motor vehicle driver to 

drive more than 11 hours.

(d) The list of the acute and critical regulations which are used in determining 

safety ratings is included at the end of this document.

(e) Noncompliance with acute regulations and patterns of noncompliance with 

critical regulations are quantitatively linked to inadequate safety management 

controls and usually higher-than-average accident rates. The FMCSA has used 

noncompliance with acute regulations and patterns of noncompliance with critical 

regulations since 1989 to determine motor carriers’ adherence to the safety fitness 

standard in §385.5.

(f) The regulatory factors, evaluated on the basis of the adequacy of the carrier’s 

safety management controls, are (1) Parts 387 and 390; (2) Parts 382, 383, and 

391; (3) Parts 392 and 395; (4) Parts 393 and 396, when there are less than 3 

vehicle inspections in the last 12 months to evaluate; and (5) Parts 397, 171, 177, 

and 180.

(g) For each instance of noncompliance with an acute regulation or each pattern of 

noncompliance with a critical regulation during the compliance review, one point 

will be assessed. A pattern is more than one violation. When a number of 

documents are reviewed, the number of violations required to meet a pattern is 

equal to at least 10 percent of those examined.

(h) However, each pattern of noncompliance with a critical regulation relative to 

Part 395, Hours of Service of Drivers, will be assessed two points.
Appendix D 121 Highway Accident Report

Part VII. List of Acute and Critical Regulations

• §382.115(a): Failing to implement an alcohol and/or controlled substances 

testing program (domestic motor carrier) (acute).

• §382.201: Using a driver known to have an alcohol concentration of 0.04 or 

greater (acute).

• §382.211: Using a driver who has refused to submit to an alcohol or controlled 

substances test required under Part 382 (acute).

• §382.213(b): Using a driver known to have used a controlled substance 

(acute).

• §382.215: Using a driver known to have tested positive for a controlled 

substance (acute).

• §382.301(a): Using a driver before the motor carrier has received a negative 

preemployment controlled substance test result (critical).

• §382.303(a): Failing to conduct post accident testing on driver for alcohol 

and/or controlled substances (critical).

• §382.305: Failing to implement a random controlled substances and/or an 

alcohol testing program (acute).

• §382.305(b)(1): Failing to conduct random alcohol testing at an annual rate of 

not less than the applicable annual rate of the average number of driver 

positions (critical).

• §382.305(b)(2): Failing to conduct random controlled substances testing at an 

annual rate of not less than the applicable annual rate of the average number of 

driver positions (critical).

• §382.309(a): Using a driver who has not undergone a return-to-duty alcohol 

test with a result indicating an alcohol concentration of less than 0.02 (acute).

• §382.309(b): Using a driver who has not undergone a return-to-duty controlled 

substances test with a result indicating a verified negative result for controlled 

substances (acute).

• §382.503: Allowing a driver to perform safety sensitive functions, after 

engaging in conduct prohibited by subpart B, without being evaluated by a 

substance abuse professional, as required by §382.605 (critical).

• §382.505(a): Using a driver within 24 hours after being found to have an 

alcohol concentration of 0.02 or greater but less than 0.04 (acute).

• §382.605(c)(1): Using a driver who has not undergone a return-to-duty alcohol 

test with a result indicating an alcohol concentration of less than 0.02 or with a 

verified negative test result, after engaging in conduct prohibited by Part 382 

Subpart B (acute).
Appendix D 122 Highway Accident Report

• §382.605(c)(2)(ii): Failing to subject a driver who has been identified as 

needing assistance to at least six unannounced followup alcohol and/or 

controlled substance tests in the first 12 months following the driver’s return to 

duty (critical).

• §383.23(a): Operating a commercial motor vehicle without a valid CDL 

(critical).

• §383.37(a): Knowingly allowing, requiring, permitting, or authorizing an 

employee with a CDL which is suspended, revoked, or canceled by a State or 

who is disqualified to operate a commercial motor vehicle (acute).

• §383.37(b): Knowingly allowing, requiring, permitting, or authorizing an 

employee with more than one CDL to operate a commercial motor vehicle 

(acute).

• §383.51(a): Knowingly allowing, requiring, permitting, or authorizing a driver 

to drive who is disqualified to drive a commercial motor vehicle (acute).

• §387.7(a): Operating a motor vehicle without having in effect the required 

minimum levels of financial responsibility coverage (acute).

• §387.7(d): Failing to maintain at principal place of business required proof of 

financial responsibility (critical).

• §387.31(a): Operating a passenger-carrying vehicle without having in effect 

the required minimum levels of financial responsibility (acute).

• §387.31(d): Failing to maintain at principal place of business required proof of 

financial responsibility for passenger-carrying vehicles (critical).

• §390.15(b)(2): Failing to maintain copies of all accident reports required by 

State or other governmental entities or insurers (critical).

• §390.35: Making, or causing to make, fraudulent or intentionally false 

statements or records and/or reproducing fraudulent records (acute).

• §391.11(b)(4): Using a physically unqualified driver (acute).

• §391.15(a): Using a disqualified driver (acute).

• §391.45(a): Using a driver not medically examined and certified (critical).

• §391.45(b)(1): Using a driver not medically examined and certified during the 

preceding 24 months (critical).

• §391.51(a): Failing to maintain driver qualification file on each driver 

employed (critical).

• §391.51(b)(2): Failing to maintain inquiries into driver’s driving record in 

driver’s qualification file (critical).

• §391.51(b)(7): Failing to maintain medical examiner’s certificate in driver’s 

qualification file (critical).
Appendix D 123 Highway Accident Report

• §392.2: Operating a motor vehicle not in accordance with the laws, ordinances, 

and regulations of the jurisdiction in which it is being operated (critical).

• §392.4(b): Requiring or permitting a driver to drive while under the influence 

of, or in possession of, a narcotic drug, amphetamine, or any other substance 

capable of rendering the driver incapable of safely operating a motor vehicle 

(acute).

• §392.5(b)(1): Requiring or permitting a driver to drive a motor vehicle while 

under the influence of, or in possession of, an intoxicating beverage (acute).

• §392.5(b)(2): Requiring or permitting a driver who shows evidence of having 

consumed an intoxicating beverage within 4 hours to operate a motor vehicle 

(acute).

• §392.6: Scheduling a run which would necessitate the vehicle being operated 

at speeds in excess of those prescribed (critical).

• §392.9(a)(1): Requiring or permitting a driver to drive without the vehicle’s 

cargo being properly distributed and adequately secured (critical).

• §395.1(h)(1)(i): Requiring or permitting a property-carrying commercial motor 

vehicle driver to drive more than 15 hours (driving in Alaska) (critical).

• §395.1(h)(1)(ii): Requiring or permitting a property-carrying commercial 

motor vehicle driver to drive after having been on duty 20 hours (driving in 

Alaska) (critical).

• §395.1(h)(1)(iii): Requiring or permitting a property-carrying commercial 

motor vehicle driver to drive after having been on duty more than 70 hours in 7 

consecutive days (driving in Alaska) (critical).

• §395.1(h)(1)(iv): Requiring or permitting a property-carrying commercial 

motor vehicle driver to drive after having been on duty more than 80 hours in 8 

consecutive days (driving in Alaska) (critical).

• §395.1(h)(2)(i): Requiring or permitting a passenger-carrying commercial 

motor vehicle driver to drive more than 15 hours (driving in Alaska) (critical).

• §395.1(h)(2)(ii): Requiring or permitting a passenger-carrying commercial 

motor vehicle driver to drive after having been on duty 20 hours (driving in 

Alaska) (critical).

• §395.1(h)(2)(iii): Requiring or permitting a passenger-carrying commercial 

motor vehicle driver to drive after having been on duty more than 70 hours in 7 

consecutive days (driving in Alaska) (critical).

• §395.1(h)(2)(iv): Requiring or permitting a passenger-carrying commercial 

motor vehicle driver to drive after having been on duty more than 80 hours in 8 

consecutive days (driving in Alaska) (critical).

• §395.1(o): Requiring or permitting a property-carrying commercial motor 

vehicle driver to drive after having been on duty 16 consecutive hours 

(critical).
Appendix D 124 Highway Accident Report

• §395.3(a)(1): Requiring or permitting a property-carrying commercial motor 

vehicle driver to drive more than 11 hours (critical).

• §395.3(a)(2): Requiring or permitting a property-carrying commercial motor 

vehicle driver to drive after the end of the 14th hour after coming on duty 

(critical).

• §395.3(b)(1): Requiring or permitting a property-carrying commercial motor 

vehicle driver to drive after having been on duty more than 60 hours in 7 

consecutive days (critical).

• §395.3(b)(2): Requiring or permitting a property-carrying commercial motor 

vehicle driver to drive after having been on duty more than 70 hours in 8 

consecutive days (critical).

• §395.3(c)(1): Requiring or permitting a property-carrying commercial motor 

vehicle driver to restart a period of 7 consecutive days without taking an offduty period of 34 or more consecutive hours (critical).

• §395.3(c)(2): Requiring or permitting a property-carrying commercial motor 

vehicle driver to restart a period of 8 consecutive days without taking an offduty period of 34 or more consecutive hours (critical).

• §395.5(a)(1): Requiring or permitting a passenger-carrying commercial motor 

vehicle driver to drive more than 10 hours (critical).

• §395.5(a)(2): Requiring or permitting a passenger-carrying commercial motor 

vehicle driver to drive after having been on duty 15 hours (critical).

• §395.5(b)(1): Requiring or permitting a passenger-carrying commercial motor 

vehicle driver to drive after having been on duty more than 60 hours in 7 

consecutive days (critical).

• §395.5(b)(2): Requiring or permitting a passenger-carrying commercial motor 

vehicle driver to drive after having been on duty more than 70 hours in 8 

consecutive days (critical).

• §395.8(a): Failing to require driver to make a record of duty status (critical).

• §395.8(e): False reports of records of duty status (critical).

• §395.8(i): Failing to require driver to forward within 13 days of completion, 

the original of the record of duty status (critical).

• §395.8(k)(1): Failing to preserve driver’s record of duty status for 6 months 

(critical).

• §395.8(k)(1): Failing to preserve driver’s records of duty status supporting 

documents for 6 months (critical).

• §396.3(b): Failing to keep minimum records of inspection and vehicle 

maintenance (critical).

• §396.9(c)(2): Requiring or permitting the operation of a motor vehicle declared 

“out-of-service” before repairs were made (acute).
Appendix D 125 Highway Accident Report

• §396.11(a): Failing to require driver to prepare driver vehicle inspection report 

(VIR) (critical).

• §396.11(c): Failing to correct out-of-service defects listed in a driver VIR 

before the vehicle is operated again (acute).

• §396.17(a): Using a commercial motor vehicle not periodically inspected 

(critical).

• §396.17(g): Failing to promptly repair parts and accessories not meeting 

minimum periodic inspection standards (acute).

• §397.5(a): Failing to ensure a motor vehicle containing Division 1.1, 1.2, or 

1.3 (explosive) material is attended at all times by its driver or a qualified 

representative (acute).

• §397.7(a)(1): Parking a motor vehicle containing Division 1.1, 1.2, or 1.3 

materials within 5 feet of traveled portion of highway or street (critical).

• §397.7(b): Parking a motor vehicle containing hazardous material(s) other than 

Division 1.1, 1.2, or 1.3 materials within 5 feet of traveled portion of highway 

or street (critical).

• §397.13(a): Permitting a person to smoke or carry a lighted cigarette, cigar, or 

pipe within 25 feet of a motor vehicle containing Class 1 materials, Class 5 

materials, or flammable materials classified as Division 2.1, Class 3, Divisions 

4.1 and 4.2 (critical).

• §397.19(a): Failing to furnish driver of motor vehicle transporting Division 

1.1, 1.2, or 1.3 (explosive) materials with a copy of the rules of Part 397 and/or 

emergency response instructions (critical).

• §397.67(d): Requiring or permitting the operation of a motor vehicle 

containing explosives in Class 1, Divisions 1.1, 1.2, or 1.3, that is not 

accompanied by a written route plan (critical).

• §397.101(d): Requiring or permitting the operation of a motor vehicle 

containing highway route-controlled quantity, as defined in §173.403, of 

radioactive materials that is not accompanied by a written route plan.

• §171.15: Carrier failing to give immediate telephone notice of an incident 

involving hazardous materials (HM) (critical).

• §171.16: Carrier failing to make a written report of an incident involving HM 

(critical).

• §172.313(a): Accepting for transportation or transporting a package containing 

a poisonous-by-inhalation material that is not marked with the words 

“Inhalation Hazard” (acute).

• §172.704(a)(4): Failing to provide security awareness training (critical).

• §172.704(a)(5): Failing to provide in-depth security awareness training 

(critical).
Appendix D 126 Highway Accident Report

• §172.800(b): Transporting HM without a security plan (acute).

• §172.800(b): Transporting HM without a security plan that conforms to 

Subpart I requirements (acute).

• §172.800(b): Failure to adhere to a required security plan (acute).

• §172.802(b): Failure to make copies of security plan available to hazmat 

employees (critical).

• §173.24(b)(1): Accepting for transportation or transporting a package that has 

an identifiable release of HM to the environment (acute).

• §173.421(a): Accepting for transportation or transporting a Class 7 

(radioactive) material described, marked, and packaged as a limited quantity 

when the radiation level on the surface of the package exceeds 0.005 mSv/hour 

(0.5 mrem/hour) (acute).

• §173.431(a): Accepting for transportation or transporting in Type A packaging 

a greater quantity of Class 7 (radioactive) material than authorized (acute).

• §173.431(b): Accepting for transportation or transporting in a Type B 

packaging a greater quantity of Class 7 (radioactive) material than authorized 

(acute).

• §173.441(a): Accepting for transportation or transporting a package containing 

Class 7 (radioactive) material with external radiation exceeding allowable 

limits (acute).

• §173.442(b): Accepting for transportation or transporting a package containing 

Class 7 (radioactive) material when the temperature of the accessible external 

surface of the loaded package exceeds 50° Celsius (C) (122° Fahrenheit [F]) in 

other than an exclusive use shipment, or 85° C (185° F) in an exclusive use 

shipment (acute).

• §173.443(a): Accepting for transportation or transporting a package containing 

Class 7 (radioactive) material with removable contamination on the external 

surfaces of the package in excess of permissible limits (acute).

• §177.800(c): Failing to instruct a category of employees in HM regulations 

(critical).

• §177.801: Accepting for transportation or transporting a forbidden material 

(acute).

• §177.817(a): Transporting a shipment of HM not accompanied by a properly 

prepared shipping paper (critical).

• §177.817(e): Failing to maintain proper accessibility of shipping papers 

(critical).

• §177.823(a): Moving a transport vehicle containing HM that is not properly 

marked or placarded (critical).
Appendix D 127 Highway Accident Report

• §177.835(a): Loading or unloading a Class 1 (explosive) material with the 

engine running (acute).

• §177.835(c): Accepting for transportation or transporting Division 1.1, 1.2, or 

1.3 (explosive) materials in a motor vehicle or combination of vehicles that is 

not permitted (acute).

• §177.835(j): Transferring Division 1.1, 1.2, or 1.3 (explosive) materials 

between containers or motor vehicles when not permitted (acute).

• §177.841(e): Transporting a package bearing a poison label in the same 

transport vehicle with material marked or known to be foodstuff, feed, or any 

edible material intended for consumption by humans or animals unless an 

exception in §177.841(e)(i) or (ii) is met (acute).

• §180.407(a): Transporting a shipment of HM in cargo tank that has not been 

inspected or retested in accordance with §180.407 (critical).

• §180.407(c): Failing to periodically test and inspect a cargo tank (critical).

• §180.415: Failing to mark a cargo tank which passed an inspection or test 

required by §180.407 (critical).

• §180.417(a)(1): Failing to retain cargo tank manufacturer’s data report 

certificate and related papers, as required (critical).

• §180.417(a)(2): Failing to retain copies of cargo tank manufacturer’s 

certificate and related papers (or alternative report) as required (critical).

For more detailed information, see <www.fmcsa.dot.gov/rules-regulations/ 

administration/fmcsr/385appnb.htm>, December 15, 2006.
128 Highway Accident Report

Appendix E

Excerpts From Federal Railroad Administration Testimony

The Federal Railroad Administration (FRA) passenger railcar regulations are 

principally found in 49 Code of Federal Regulations (CFR) Part 238, Passenger 

Equipment Safety Standards. Section 238.103 and appendix B contain specific fire safety 

requirements, which were issued in 1999 and amended in 2002. The purpose of the 

requirements generally is to prevent fire ignition, to minimize fire spread and smoke 

emissions, and to maximize the time available for passenger and crew egress. The 

majority of combustible materials used in passenger railcars and locomotive cabs, 

organized by categories and functions, are required to be tested and meet certain 

flammability and smoke emission criteria. In addition, a structural floor fire endurance test 

is required.

January 17, 1996

The FRA published an advance Notice of Proposed Rulemaking (NPRM) 

concerning the establishment of comprehensive safety standards for railroad passenger 

equipment.

February 1996

Following two serious passenger train accidents, the FRA issued Emergency Order 

No. 20, “Emergency Order Requiring Enhanced Operating Rules and Plans for Ensuring 

the Safety of Passengers Occupying the Leading Car of a Train.” Among other provisions, 

the order requires prompt action (within 60 days) by each commuter and intercity 

passenger railroad to immediately enhance emergency egress of trains by ensuring that: 

(1) each emergency exit location on every passenger car is clearly marked on the inside of 

the car and that operational instructions are posted; (2) each rescue access window is 

marked on the exterior of the car; (3) a representative sample of emergency window exits 

has been tested and is operable; and (4) each railroad discuss in an Interim Systems Safety 

Plan its programs and plans for liaison with and training of emergency responders with 

respect to emergency access to passengers, as well as the methods used to inform 

passengers of the location and method of operation of emergency exits, such as flyers, 

announcements, or messages on tickets.

June 17, 1997

As a result of the investigation of the Amtrak/MARC train collision and fire that 

occurred in Silver Spring, Maryland, on February 6, 1996, the Safety Board issued the 

following fire safety recommendation to the FRA:
Appendix E 129 Highway Accident Report

R-97-20

Require that a comprehensive inspection of all commuter passenger cars be 

performed to independently verify that the interior materials in these cars 

meet the expected performance requirements for flammability and smoke 

emissions characteristics.

September 23, 1997

The FRA published an NPRM proposing that the 1989 FRA Guidelines be made 

mandatory standards for materials used in new and refurbished passenger cars and 

locomotive cabs. In particular, the NPRM addressed Safety Recommendation R-97-20. In 

addition, the FRA included fire safety analysis requirements for evaluation of the design 

and materials of new passenger cars to ensure sufficient time for passenger evacuation 

from the train.

1998

The FRA issued the Passenger Train Emergency Preparedness final rule, which 

incorporated and superseded several requirements of Emergency Order No. 20 into 

49 CFR Parts 223 and 239. Specifically, 49 CFR 239.101 requires that each railroad’s 

emergency preparedness plan also provide for passenger awareness of emergency 

procedures to enable passengers to properly respond during an emergency; and each 

railroad must post emergency instructions inside all passenger cars and use one or more 

additional methods to provide safety awareness information.

May 12, 1999

The FRA published the Passenger Equipment Safety Standards final rule, 

containing detailed fire safety analysis requirements for new equipment to reduce the risk 

of personal injury and equipment damage caused by a fire to an acceptable level. The rule 

also included a formal safety methodology and a documented analysis checklist, which 

considers car design, materials, and ventilation. In addition, railroads were required to 

determine the extent to which overheat detection and fire suppression systems must be 

installed to ensure sufficient time for the safe evacuation of passengers and crew.

The final rule also addressed Safety Recommendation R-97-20 by requiring that 

passenger railroads perform a fire safety analysis of their existing equipment to determine 

whether materials currently installed in railcars posed an unacceptable hazard in terms of 

material quantity, location, and proximity to ignition sources. Railroads were required to 

consider the extent to which existing materials met the test criteria in appendix B of the 

rule and their potential hazard relating to the unacceptable risk of personal injuries. 

Categories of existing equipment and current rail service were to be included in the fire 

safety evaluation.
Appendix E 130 Highway Accident Report

Other Excerpts

The FRA also requires that the structural floor pass the American Society for 

Testing and Materials (ASTM) E 1191 fire endurance test. The nominal test period should 

be twice the maximum expected time under normal circumstances for a vehicle to stop 

completely and safely from its maximum operating speed, plus the time necessary to 

evacuate all vehicle occupants to a safe area. The fire resistance period required should be 

consistent with the safe evacuation of a full load of passengers from the vehicle under a 

worst case scenario. The nominal test period is a minimum of 15 minutes.

Under FRA sponsorship, the Volpe National Transportation Systems Center is 

currently conducting emergency evacuation and fire safety research to assist in 

determining whether the amount of time available to evacuate a passenger railcar is 

sufficient, given the amount of time occupants actually need to evacuate safely using the 

available emergency egress features in a railcar. The Volpe Center is using fire safetyrelated research findings to assist in determining the amount of available time for 

evacuation before conditions on board become untenable due to smoke and fire and is also 

using emergency evacuation simulations to predict the amount of time to evacuate cars 

under various circumstances and in different operating environments. Findings from this 

research may be used to supplement existing emergency egress standards.

1 American Society for Testing and Materials, Standard Test Methods for Fire Tests of Building 

Construction and Materials, ASTM E-119-05a (West Conshohocken, PA: ASTM, 2006).
131 Highway Accident Report

Appendix F

Emergency Evacuation of Special Needs Populations: Major 

Federal Studies Since Hurricanes Katrina and Rita

Catastrophic Hurricane Evacuation Plan Evaluation: A Report to Congress

Report1 recommendations 1, 4, and 6 address transport and special needs 

evacuations:

• Recommendation 1: Develop regional plans for mass evacuations in 

connection with catastrophic incidents on the scale of Hurricane Katrina. 

These plans should be developed jointly by State and local officials within the 

region in cooperation with officials from appropriate Federal agencies; 

providers of all safe and practical modes of transportation and providers of 

shelters, food, fuel, and other necessities; managers of hospitals, nursing 

homes, emergency medical services (air, ground, etc.), jails, and other 

institutions with their own evacuation plans; and representatives of various 

special needs populations. [Italics added.]

• Recommendation 4: Transportation agencies and operators should be more 

directly involved in key aspects of evacuation planning and implementation.

• Recommendation 6: State and local agencies should work with the special 

needs communities to develop systems whereby those requiring specialized 

transportation or sheltering services during evacuations can make those needs 

known to emergency managers and operators of transportation and sheltering 

services before evacuations.

Disaster Preparedness: Limitations in Federal Evacuation Assistance for 

Health Facilities

This report2 makes two recommendations for executive action, as follows:

• Clearly delineate how the Federal Government will assist State and local 

governments with the movement of patients and residents out of hospitals and 

nursing homes to a mobilization center, where National Disaster Medical 

System (NDMS) transportation begins.

1 U.S. Department of Transportation and U.S. Department of Homeland Security, Catastrophic 

Hurricane Evacuation Plan Evaluation: A Report to Congress (Washington, DC: DOT, 2006).

2 U.S. Government Accountability Office, Disaster Preparedness: Limitations in Federal Evacuation 

Assistance for Health Facilities Should be Addressed (Washington, DC: GAO, 2006) 19. See 

<www.gao.gov/cgi-bin/getrpt?GAO-06-826>, September 26, 2006.
Appendix F 132 Highway Accident Report

• In consultation with the other NDMS Federal partners—the Secretaries of 

Defense, Health and Human Services, and Veterans Affairs—clearly delineate 

how to address the needs of nursing home residents during evacuations, 

including the arrangements necessary to relocate these residents.

Federal Response to Hurricane Katrina: Lessons Learned

As a lesson learned, this report3 stated:

The Department of Transportation, in coordination with other appropriate 

departments of the Executive Branch, must also be prepared to conduct mass 

evacuation operations when disasters overwhelm or incapacitate State and local 

governments.

The report made 125 recommendations for improving future Federal responses to 

disasters. Three of these recommendations concern evacuation (numbers 41, 42, and 43):4

41. Designate the DOT as the primary Federal agency responsible for developing 

the Federal Government’s capability to conduct mass evacuations when disasters 

overwhelm State and local governments. The DOT should, in coordination with 

the U.S. Department of Health and Human Services, the U.S. Department of 

Defense, the U.S. Department of Veterans Affairs, the U.S. Department of 

Homeland Security (DHS), and the American Red Cross, plan, train, and conduct 

exercises for the timely evacuation of patients and transportation of medical 

supplies and personnel.

42. The DHS should require State and local governments, as a condition for 

receiving Homeland Security grants, to develop, implement, and exercise 

emergency evacuation plans and to cooperate fully with all Federal evacuation 

activities.

43. The DHS should, in coordination with the DOT, evaluate all State evacuation 

plans as well as the evacuation plans of the 75 largest urban areas.

3 The White House, The Federal Response to Hurricane Katrina: Lessons Learned (Washington, DC: 

2006) 57. See <www.whitehouse.gov/reports/katrina-lessons-learned/>, September 26, 2006.

4 The Federal Response to Hurricane Katrina: Lessons Learned, 99–100.