18

The police report indicated that the occupants were not wearing seatbelts.
Following the crash, the State Police Motor Carrier Inspection Division officer
inspected the accident vehicle. The only problem noted was that the "female ends
of both seatbelts were found tucked under the seat, rendering them unusable." The
cab was intact after the accident.

Dallas, Texas.--About 1:54 p.m., on August 5, 1990, Dallas Fire Department
engine 9, a 1990 Quality firetruck with four-occupants, was responding to a medical
emergency and was traveling south on South Beltline Road. The driver released the
accelerator while he was traveling down a hill that curved to the left; the rear of the
apparatus began to skid to the right. The apparatus skidded sideways down the
road until the right front tires hit the soft dirt shoulder-on the left side of the road
and the apparatus rolled over and came to rest 30 feet from the road facing north.
(See figure 3.) It was drizzling rain, and.the pavement was wet. The driver and
officer in the cab and the two firefighters in. the jumpseat were wearing their
seatbelts. Although the damage to the apparatus was extensive, there were no
injuries. :

Figure 3.--Dallas, Texas, Fire Department engine 9.
(photograph courtesy of Dallas Fire Department.)


11

After the implementation of a MCSAP random roadside inspection program in
Connecticut in 1986, the percentage of vehicles that had to be removed from service
because of out-of-service violations declined,20 indicating an improvement in the
general condition of the commercial vehicles on the road. Fire apparatus are
equipped with many of the same mechanical features as other heavy trucks and can
do fully as much damage in the event of an accident. However, most States do not
have an oversight program for these vehicles that is comparable to the MCSAP
inspections for heavy trucks. For example, although the Tarrant County, Texas, fire
apparatus was inspected shortly before the accident, the vehicle was not taken out
of service even though the apparatus was in poor condition. The Texas inspection
did not provide the level of scrutiny that an inspection under MCSAP (mechanical)
criteria would have provided. Additionally, the voluntary inspections of fire
apparatus in Connecticut indicate that many of these vehicles are not maintained
properly.

Currently, MCSAP programs do not include fire apparatus, and because of the
random nature of MCSAP inspections, the Safety Board believes that it would be
inappropriate to include them in MCSAP. However, the Safety Board believes that
an improvement in the condition of fire apparatus could be expected if these
vehicles were Subjected to the level of inspections that commercial vehicles receive
through MCSAP. Therefore, the Safety Board believes that States should require the
inspection of fire apparatus and that these inspections should be performed by
commercial vehicle inspectors in accordance with MCSAP (mechanical) criterion to
ensure continuity in the depth and level of the inspections.

20in 1986 70 percent of the heavy commercial vehicles inspected during CDMV. MCSAP random

roadside inspections failed or were put out of service because of safety violations; in 1990, 40 percent
failed.


24

--to the National Fire Protection Association:

Cooperate with the U.S. Fire Administration and the International
Association of Fire Chiefs to encourage fire departments to
establish and enforce mandatory seatbelt policies and to develop
programs that promote the use of seatbelts in fire apparatus. (Class
ll, Priority Action) (H- 91-11)

--to the Governors and legislative bodies of those States without fire apparatus
inspection programs:

Develop and implement a fire-apparatus inspection program that
requires periodic inspections performed by commercial vehicle
inspectors in accordance with the Federal Highway Administration
Motor Carrier Assistance Program vehicle (mechanical) inspection
criterion. (Class'll, Priority Action) (H-91-12)

BY THE NATIONAL TRANSPORTATION SAFETY BOARD

/s/ James L. Kolstad
Chairman

/s/ Susan M. Coughlin
> Vice Chairman

/s/ Jim Burnett
Member

/s/ John K. Lauber
Member

._ /s/ Christopher A. Hart
Member

March 19, 1991


NATIONAL TRANSPORTATION SAFETY BOARD
WASHINGTON, D.C. 20594

SPECIAL INVESTIGATION REPORT
EMERGENCY FIRE APPARATUS
INTRODUCTION

On May 10, 1990, a 1974 Hahn custom pumper fire engine operated by the
Waterbury Fire Department (WFD), while responding to an emergency call in
Waterbury, Corinecticut, ran off the road and hit a large tree when the driver lost
control on a steep downgrade. The fire engine carried five paid firefighters and
500 gallons of water. Two firefighters were fatally injured, one firefighter sustained
moderate injuries, and the driver and remaining firefighter sustained only minor
injuries. The pavement was wet from previous rain.

This accident and several others involving emergency fire. apparatus!
responding to alarms prompted the Safety Board to conduct a special investigation
to determine the adequacy of fire apparatus maintenance and inspection, fire
department operating procedures, and occupant seatbelt use. National Fire
Protection Association (NFPA)2 data indicate that between 1980 and 1989,
15 percent of all firefighters who died in the line of duty died as a result of accidents
involving fire apparatus that were en route to alarms.4 As part of this special
investigation, the Safety Board examined 8 separate fire apparatus accidents and
conducted an informal survey of the 50 States and the District of Columbia to
determine their requirements for inspecting fire apparatus.

1For the purposes of this report, “fire apparatus” refers to the heavy fire vehicles, such as
pumpers/engines, ladder trucks, heavy squad units, 10,000 pounds and over, that transport people,
and specialized equipment, such as foam/crash units used at airports.

2The National Fire Protection Association (NFPA), organized in 1896, is an independent, voluntary
membership, nonprofit organization that develops voluntary standards and codes which serve as
guidelines for the fire services in all phases of operations.

3One hundred and seventy-nine firefighters.
4See appendix A for further information concerning NFPA accident data.


@

19

National Fire Protection Association Standards

The NFPA is an independent, voluntary-membership, nonprofit organization.
More than 200 NFPA committees develop voluntary standards and codes that serve
as guidelines for the fire services in all phases of operations. These standards are
updated every 3 to 5 years; however, they are not mandatory.

The 1987 NFPA Standard 1500, “Fire Department Occupational Safety and
Health Program," Chapter 4, "Vehicles and Equipment," Section 3," Persons Riding
on Fire Apparatus,” states:

4-3.1 All persons riding on fire apparatus shall be seated and

secured to the vehicle by seat belts or safety harnesses at any time

the vehicle is in motion. Riding on tailsteps or in any other exposed

positions shall be specifically prohibited. Standing while riding shall
e specifically prohibited.

Fire Apparatus Occupant Seatbelt Use

In the Catlett, Virginia, accident four unrestrained firefighters were ejected
from the apparatus, and two of these firefighters were fatally injured. Even though
the fire apparatus was heavily damaged, the cab section remained intact. In the
Gallitzin Township, Pennsylvania, accident, both unrestrained occupants were
ejected. However, the apparatus passenger compartment remained intact. The
NHTSA Fatal Accident Reporting System (FARS) 1988 data concerning fatal accidents
indicate that 17.4 percent of the unrestrained passenger-car occupants were ejected
from the vehicle; of those ejected, 73.5 percent were fatally injured. Although there
is no similar data concerning occupant ejection as a result of accidents involving fire
apparatus, it is clear that ejection from a vehicle during a collision is likely to cause a
serious or fatal injury.

In contrast, several accidents in which fire apparatus overturned and the
restrained occupants remained within the apparatus and were not injured illustrate
the benefits of using seatbelts. In the Los Angeles, California, accident and in the
Eugene, Oregon, accident, the vehicles overturned, yet the firefighters, who had
used their seatbelts, received only minor injuries. In the Dallas, Texas, accident the
fire apparatus rolled over and came to rest 30 feet from the road; however, the four
firefighters were uninjured. Accordingly, it is likely that had the occupants of the
Catlett, Virginia, and Gallitzin. Township, Pennsylvania, accident vehicles been
restrained, they might not have been ejected and might:have been less severely
injured.

NFPA voluntary standard 1500 clearly states that all persons shall be seated and
restrained while riding on fire apparatus, and most departments have policies
requiring the use of seatbelts. Yet, firefighters continue to be injured and killed
because they are not restrained. Fire apparatus are frequently operated at higher
speeds than conventional vehicles are and, therefore, are prone to overturn and
high-speed accidents. It is essential for firefighters to wear available seatbelts to
prevent ejection and injury. Although there are voluntary standards that encourage
seatbelt use, there is no nationwide program to educate the firefighting community
concerning the benefits of seatbelts. Thus, the Safety Board believes that the USFA,
in cooperation with the [AFC and the NFPA, should encourage fire departments to
establish and enforce mandatory seatbelt policies and to develop programs that
promote the use of seatbelts in fire apparatus.


29

APPENDIX C

INSPECTION REQUIREMENTS FOR FIRE APPARATUS

State

Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii

Idaho

Ilinois
Indiana

lowa

Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada

New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio

PMVia

PEE RE OK KE KK Eg

Periodic motor venicle inspection.
b PMVI for commercial vehicles is currently limited to liquid propane gas (LPG) carriers.
Since 1989 California has required all commercial carriers to be inspected every 90 days.

dVoluntary program.

Commercial PMVI

-b

PEE EK TOK! Ye eK KK RK

eAmbulances are required to be inspected. Fire apparatus are not.

fMinnesota started a PW! program for commercial vehicles in Apri! 1991.
9Fire apparatus inspection is required by the State Fire Marshall's Office.

Fire Apparatus

i a 2

,
®

‘ XK RK! "RK KK KK


23.

@ RECOMMENDATIONS

As a result of this special Investigation, the National Transportation Safety
Board made the following recommendations:

--to the U.S. Fire Administration of the Federal Emergency Management
Agency:

Urge fire departments to establish vehicle maintenance programs
that follow all of the manufacturers service requirements and
schedules. (Class Il, Priority Action) (H-91-3)

Inform fire departments nationwide of the potential hazards of
misusing engine retarders, and encourage fire departments to
establish operating procedures that are consistent with
manufacturers warnings about the proper use of engine retarders.
(Class Il, Priority Action) (H-91-4)

Notify fire departments of the hazards of using fire apparatus
manual brake limiting valves, and urge them to discontinue the use
of these devices. (Class Il, Priority Action) (H-91-5)

In cooperation with the National Fire Protection Association and

the International Association of Fire Chiefs, encourage fire

5 departments to establish and enforce mandatory seatbelt policies

®@ and to develop programs that promote the use of seatbelts in fire
apparatus. (Class II, Priority Action) (H-91-6)

--to the International Association of Fire Chiefs:

Urge fire departments to establish vehicle maintenance programs
that follow all of the manufacturers service requirements and
schedules. (Class Il, Priority Action) (H-91-7)

Inform fire departments nationwide of the potential hazards of
misusing engine retarders, and encourage fire departments to
establish operating procedures that are consistent with
manufacturers warnings about the proper use of engine retarders.
(Class Ul, Priority Action) (H-91-8)

Notify fire departments of the hazards of using fire apparatus
manual brake limiting valves, and urge them to discontinue the use
of these devices. (Class Il, Priority Action) (H-91-9)

Cooperate with the U.S. Fire Administration and the National Fire
Protection Association to encourage fire departments to establish
and enforce mandatory seatbelt policies and to develop programs
that promote the use of seatbelts in fire apparatus. (Class Il, Priority
Action) (H-91-10) .


16

braking is good under all conditions. Tests have shown front wheel
skids from braking are not likely even on ice. Make sure the control
is in the "normal" position to have normal stopping power.

According to a published NHTSA report,26 a two-axle vehicle that weighs
27,300 pounds consistently performs better with the front axle limiting valve in the
“dry road" position, even on a wet road surface. "Use of a limiting valve on this
[type of] vehicle appears unwise; it degrades performance.” This research program
was completed in 1985.

== Currently, the Safety Board is conducting a nationwide study of heavy-vehicle
brake performance that evaluates nationwide data on inspections and accidents
involving commercial vehicles. The results of the study will be used as a basis for
making more definitive recommendations concerning the use of brake limiting
valves on other types of highway vehicles.. Many of the older fire service apparatus
are equipped with a dry road/slippery road brake limiting valve. Because fire
apparatus often stop suddenly, because they are frequently operated at higher
speeds than are conventional vehicles, and because they are operated under
hazardous conditions, the Safety Board concludes that the use of manual brake
limiting valves can diminish the apparatus stopping capability and, therefore, their
use should be discontinued. .

26U.S. DOT, NHTSA DOT HS 806 738, Interim Report “NHTSA Heavy Duty Brake Research Program,
Report No. 1--Stopping Capability of Air Brake Vehicles. Volume |: Technical Report.”

®


@

The rear axle brake chamber push-rod. adjustments were within operating limits on
the right side and at the maximum operating limit on the left side. The air chambers
were misaligned, and the push rods had severe wear markings on the sides.”

If only one brakeshoe out of four makes contact with one of the two drums,
the rear axle receives only 25 percent of the brake retarding force that it should.
According to Safety Board calculations, which took into account the size of the air
chamber (24 square inches on the front axle and 30 square inches on the rear axle)
and which assumed an air pressure application of 100 psi, the rear axle brakes were
in such poor condition that the apparatus had only 58 percent of its original braking
capability. The driver indicated that the wet/dry switch was in the wet position,
thus providing only 50 percent of the braking capability of the front axle. (See "Fire
Department Operating Procedures.") The condition of the rear axle brakes, coupled
with the use of the wet/dry switch in the wet position, reduced the original braking
capability of the vehicle to about 36 percent. :

The accumulated rust around the anchor pins of the WFD apparatus rear axle
brakes indicated that they were in need of lubrication. According to the
manufacturer's service manual, the brakeshoe pins should be cleaned and lubricated
after every 500 hours of use. Based on the hour-meter recorded. measurements, the
accident vehicle's brakeshoe pins should have been serviced in November 1989. The
rust and the frozen condition of the pins indicate that the service was not
performed. The Safety Board concludes that the BAR did not adequately maintain
the accident vehicle's brakes and did not follow the manufacturer's recommended
service guidelines. :

The WFD BAR policy was that fire apparatus should receive preventive
maintenance after every 150 hours of operation, as measured by the engine
hour-meters. A.review of the service records for the accident vehicle shows that in
September 1988 it received a 150-hour service check although it had been in service
for 267 hours since its last check. In November 1989, 468 hours of service later, it
received its next check. The Safety Board concludes that the BAR did not adhere to
its own policy of servicing a vehicle after every 150 hours of service. The
manufacturer's service intervals are intended to insure that a vehicle performs as
designed. Service intervals of 50 hours were recommended by the manufacturer's
maintenance manual for the WFD accident vehicle. Most vehicle manufacturers
recommend service based on either the amount of use or elapsed time, whichever
comes first, because a vehicle can deteriorate even while it is idle. Lubricants can dry

out, and rust and corrosion can develop, especially in the case of spare vehicles that
may be used infrequently.

The Tarrant County, Texas, SVFD had 6 vehicles (a tanker, two engines, a rescue
vehicle, and two grass trucks).. The SVFD did not have a formal maintenance
program or record system. It did change the oil in its vehicles every 3 or 4 months
and did take the vehicles to an outside shop for repair when they were not
functioning properly.

7See appendix B for further information concerning the condition of the brake.

8Many vehicles use a manual limiting valve (commonly called a dry road/slippery road valve or wet/dry
switch) that is controlled by a pneumatic switch in the cab. In the “dry road" position, the valve is a

1:1 valve. -in the “slippery road" position, it reduces front brake pressure to 50 percent of control line
pressure at all control line pressure levels.



APPENDIX D 32

H-89-43 ©

Urge your members to install the advisory placards provided by the
engine retarder manufacturers that warn against using the retarder
on slippery/wet surfaces when the vehicle is empty or lightly loaded
or that warn against using the engine retarder to shift gears in these
conditions. (Closed--Acceptable Action)

--to the manufacturers of engine retarders:
H-89-44
Revise existing owner's manuals and placards to warn against the
use of the engine retarder on slippery/wet surfaces when the vehicle
is empty or lightly loaded, and call special attention to this warning
in the owner's manuals for drivers operating a single-driver axle
tractor. (Closed-- Acceptable Action)

--to the Federal Highway Administration:
H-89-45
Include in the commercial driver's license testing procedures

questions regarding the proper operation of engine retarder
systems. (Closed--Reconsidered)

* U.S. G.P.0.:1991-281-626-20038


Figure 1.«-Hahn custom pumper, Model HCP-15.
(similar to the accident vehicle.)

Tarrant County, Texas.--About 2:34 p.m., on October 24, 1990, a Spillway
Volunteer Fire Department (SVFD) firefighter was dispatched in a tanker truck to
transport 1,000 gallons of water to other firefighters at the scene of a house fire in
rural Tarrant County, Texas. Before departing on the fire call, she had been
babysitting the fire chief's 2-year-old daughter. She was unable to find another
babysitter and took the infant with her. The 1963 International Loadstar 1600
firetruck was not equipped with seatbelts, and the infant was not restrained in a
child safety seat. ‘* .

@


MAINTENANCE AND INSPECTION

Accident Information

Waterbury, Connecticut.--On May 10, 1990, at 11:19 a.m. eastern standard
‘time, a 1974 Hahn custom pumper, Model HCP12-24, with two jumpseatss was
dispatched from the WFD Highland Avenue fire house to an alarm on Thomaston
Avenue in Waterbury, Connecticut. (See figure 1.) The driver stated that after the
alarm sounded, he started the vehicle and observed that the brake system air
pressure was 120 psi (within normal operating limits).

According to the driver, the apparatus was functioning normally while heading
north on Highland Avenue. As the driver approached Chase Parkway, he slowed the
vehicle. by downshifting the automatic transmission from drive to drive 2, applied
the brakes, and came to a stop at the intersection. Highland Avenue at this location
is straight and level. The driver stated that the brakes worked “okay” and that he
had no trouble stopping. The driver then crossed Highland Avenue, successfully
negotiated a sharp turn with a radius of 355 feet), and proceeded down the 10-to
13-percent grade to the intersection of West Main Street. The driver stated that he
slowed through the sharp turn by downshifting. ”

On the steep grade, he downshifted again and applied the brakes but "did not
feel any braking."”. He then downshifted to drive 1 and applied the brakes and
parking brake (spring brake), but the parking brake button kept "popping" back.¢
He stated that the only deceleration he could detect was from the transmission.
When he reached the intersection of Highland Avenue and West Main Street, he
made a right turn into the westbound lane of West Main Street. He saw traffic
backed up from the light at a nearby intersection and attempted an immediate left
turn into an apartment complex parking lot. The fire engine ran over a 7-inch curb,
and the driver stated that he saw a tree and tried to steer away from it. The fire
engine traveled about 38 feet on the grass and collided with a tree that had two
trunks. (See figure 2.)

As a result of the collision with the tree, the driver, and firefighter who had
been seated in the left jumpseat received minor injuries. The firefighter seated in the
right front seat received moderate injuries. All of these firefighters were restrained
by lap belts. The firefighter in the right jumpseat was fatally injured, (the Safety
Board could not determine whether this firefighter was restrained by the available
lap belt). The firefighter standing behind the right jumpseat, who was unrestrained,
was fatally injured. None of the occupants were ejected. The right front of the cab
sustained most of thedamage. © :

S5This fire apparatus was a spare vehicle that was in use because the first-line fire apparatus was being
serviced.

6The parking brake for this fire apparatus was controlled by a push/pull control valve located on the
apparatus instrument panel. The Hahn operating manual states: “To set the parking brake on the

rear axle chambers, pull out the parking brake control. To release the parking brake, push control
in."



@

17

OCCUPANT SEATBELT USE

Accident Information

Catlett, Virginia.--About 7:38 p.m. on September 28, 1989, wagon 7 of the
Catlett Volunteer Fire Company was struck on its left side by a southbound National
Railroad Passenger Corporation (AMTRAK) train. The accident occurred at a
private-driveway grade crossing off Virginia Route 28 about 1 mile south of Catlett,
Virginia.27_ The cab and chassis of the apparatus rotated counterclockwise
450 degrees during the collision and came to rest facing north about 80 feet
southeast of the crossing. Most of the apparatus was destroyed; however, the
passenger compartment of the canopy cab remained intact. The unrestrained driver
and the other firefighter seated in the cab were ejected and fatally injured, and two
unrestrained firefighters riding in the rear-facing canopied jumpseat behind the cab
were ejected and sustained moderate to severe injuries. A fifth firefighter riding in
the rear-facing jumpseat remained within the apparatus following the collision. He
received serious injuries. : .

Eugene, Oregon.--About 6:09 a.m., on January 30, 1990, a Crow Valley Fire
Protection District 1989 Pierce pumper fire engine responding to a house fire
overturned while traversing a residential driveway which collapsed. The
engine-pumper overturned 1.5 times down a 20-foot incline and came to rest on its
roof. The apparatus was occupied by three firefighters, who were restrained by
seatbelts. All of the firefighters remained within the apparatus during the overturn.
Following the accident all of the firefighters were treated for minor injuries and
released | rom the hospital.

Los Angeles, California.--On March 1, 1990, engine 91, a Seagrave firetruck of
the Los Angeles City Fire Department, left the station house on a nonemergency run
(no lights or siren) and was struck broadside at the intersection of Borden Avenue
and Polk Street in-the Sylmar section of Los Angeles by an automobile that failed to
stop for a red light. as oe 7 .

The firé apparatus was hit on the right side behind the rear axle. The police
estimated that the automobile'sspeed was “well in excess of 55 mph." Asa result of
the collision, the apparatus rotated approximately 90 degrees and overturned onto
its. roof. The driver and an officer.were seated in the forward cab section, and the
two firefighters were seated facing rearward in the jumpseat in the enclosed rear
cab section. The firetruck cab remained intact during:the crash, and all of the
firefighters ‘were wearing their seatbelts. The firefighters ‘received only minor
injuries. The driver of the automobile was fatally injured... -

: : ‘

Gallitzin Township, Pennsylvania.--About 2:45°p on ‘May 17, 1990, the
Cresson Volunteer Fire Company responded to an emergency call about a motor
vehicle accident. As the 1968 Chevrolet firetruck was traveling northbound downhill
on State Route 53, the driver lost control of the vehicle. The rear of the vehicle struck
and rode up on a guardrail, and the vehicle overturned more than 360 degrees.. The
vehicle then struck a bridge abutment, traveled over the sidé of the bridge, and
came to rest on its left side in a creek bed. Both occupants were ejected onto the
roadway and were fatally injured.

27See docket HY-514-89 for further information concerning this accident.


Generally, spare fire apparatus are used only when the first-line apparatus are
out of service for maintenance or repair. In January 1990, the WFD purchased new
equipment, and the accident fire apparatus was taken out of first-line service as
engine 9 at.the Northside fire house on January 27, 1990. The accident fire
apparatus eventually became the first-line spare at the fire house on Highland
Avenue. At the time of the accident, the WFD had three ladder trucks and five
engines in spare service. They were under the same maintenance schedule as the
regular first-line apparatus.

All the WFD fire apparatus had hour meters that recorded engine running time
and were used to determine when vehicle service was needed. Under the WFD
preventive maintenance program, a vehicle was to be serviced after 150 hours of
operation. The 150-hour service check included changing the engine oil and filter,
lubricating the chassis, checking all fluids, and inspecting all belts, hoses, batteries,
tires, exhaust system, fuel system, steering, suspension, and brakes: The service
manual for the 1974 Hahn pumper, which was the accident vehicle, recommends
service every 50 hours. ,

The master mechanic stated that the BAR also performs an annual service check
on each vehicle that includes the items on the 150-hour service check, changing the
fuel, automatic transmission, water, and air filters, and changing the pump transfer
gear case and rear axle carrier case oil. Any reouilding of components (brakes,
transmission, etc.) is normally performed at this time. A service reminder (a 4-inch by
8-inch index card) is posted in the cab of the apparatus and states the hour meter
reading for the next 150-hour service check and the date of the next annual service
check. It is the responsibility of the personnel where the apparatus is stationed to
notify the BAR. when a vehicle is due for -‘maintenance. Additionally, the WFD
accident driver stated that shift duty drivers normally inspect their vehicles (pre-trip)
at the beginning of a 3-day duty shift; this inspection includes a check of all fluids
and an examination of the tires for damage, low air pressure, and tread wear, but no
road tests are performed.

Of the 12 ‘request-for-repair forms filed on the accident vehicle between
November 7, 1988, and May 3, 1940, 7 were requests to fix the brakes. Most of the
forms had notes indicating that the brakes had been checked or adjusted. A request
for repair dated May 3, 1990, stated that "the maxi brake doesn't hold on hills and
the regular [brakes] have a hard time stopping the engine on emergency runs." No
records or available information. indicated that the brakes had been repaired.
Earlier in the morning on the day of the accident, the crew took the accident vehicle
to the BAR to exchange the 24-foot extension ladder. While there, the driver talked
to the master mechanic about the brakes. The driver indicated that the master
mechanic checked the air pressure and made several brake applications. He told the
driver there were no mechanics in the shop at that time and that if the driver
brought the engine back after lunch, someone would adjust the brakes. Shortly
after the engine company returned to the fire station, it responded to the call that
resulted in the accident. .

_.:. The fire engine was equipped with an automatic transmission and
air-mechanical service brakes. A mechanical examination of the vehicle following
the accident indicated that the front axle brakes had no defects and that the
push-rod adjustments were within operating limits. An accumulation of rust was
observed in both the left and right rear axle brakes. Three of the four rear axle
brakeshoes were not making contact with the drum upon application. The lower
left and both the upper and lower right brakeshoes were frozen at the anchor pins.


@

25

APPENDIXES
APPENDIX A
, ACCIDENT DATA

The Safety Board examined published NFPA accident data from 1980 through
1989 (summarized in the table below). In this 10-year period there were 1,191
firefighter fatalities; 262 fatalities, or 22 percent, occurred in apparatus or motor
vehicle accidents. Of the 262, 179 (15 percent of the 1,191 fatalities) occurred in fire
department vehicles, and 59 (5 percent of the 1,191 fatalities) occurred in personal
vehicles.

National Fire Protection Association

Accident Data
1980-1989
Apparatus
Total fire- or motor Fire
fighter Career/ vehicle department Personal

Year fatalities volunteer accident vehicle vehicle
1980 134 67/67 21 (21%) 19 6
1981 123 64/59 20 (16%) 11 4
1982 117 49/68 23 (19%) 16 2
1983 106 58/48 21 (20%) 15 6
1984 116 47/69 32 (27%) 25 5
1985 119 57/62 23 (19%) 17 5
1986 113 60/53 27 (23%) 24 7
1987 124 52/72 33 (27%) 20 10
1988 129 48/81 33 (26%) 17 9
1989 110 46/64 21(19%) 10 5
Total 1,191 262 (22%) 179 (15%) 59 (5%)


~

~

PB91-917001
e@ NTSB/SIR-91/01

NATIONAL
TRANSPORTATION
SAFETY

BOARD

WASHINGTON, D.C. 20594

SPECIAL INVESTIGATION REPORT

EMERGENCY FIRE APPARATUS



At the time of the Waterbury accident, the State did not require the inspection
of emergency vehicles. After the accident, the CDMV initiated a voluntary non-fee
inspection program for fire service vehicles. From July 1, 1990, to January 3, 1991,
the CDMV inspected 559 fire apparatus from 64 cities and towns. During this period,
193, or 35 percent, of the fire apparatus failed the CDMV roadside inspection. Fifty
percent of the deficiencies involved brakes, 18 percent involved steering systems,
and the remaining deficiencies involved tires, suspension systems, and fuel leaks.

Texas State Inspection.--The postaccident examination of the Tarrant County,
Texas, fire apparatus disclosed numerous mechanical deficiencies, includin

under-inflated tires, worn steering components, worn brake drums, and a ruste
brake drum, all of which indicate inadequate maintenance. The apparatus had been
inspected at an inspection station designated by the Texas Department of Public
Safety (DPS) and had received an Annual Vehicle Inspection Certificate dated
October 5, 1990, which was 19 days before the accident.11 The requirements of the
Texas inspection for this apparatus consisted of 22 elements that included emissions
testing; examinations of the lights, horn, windshield wipers, and tires, and a brake
test that required the vehicle to stop within 20 feet at a speed of 10 mph. This
inspection did not include a visual or mechanical examination of the brakes.

State Vehicle Inspection Programs.--The Safety Board conducted a limited
survey of the 50 States and the District of Columbia to determine whether the States
require vehicle inspections for fire emergency vehicles. Currently, 19 States require

fire apparatus to be inspected periodically by the State or by designated fleet
inspection stations.12

Table 1--States Requiring Periodic State Fire Apparatus Inspections

Arkansas . New York
California North Carolina
Connecticut13 Oklahoma
District of Columbia Pennsylvania
Hawaii Rhode Island
Louisiana : : South Carolina
Maine , Texas
Massachusetts Utah
Mississippi Vermont

New Hampshire Washington'4

New Mexico15

11In July 1990, the DPS Motor Vehicle Inspection Unit cited the designated inspection station that had
issued the certificate for issuing certificates of. inspection without completing the required safety
inspections.

12See appendix C for further information concerning State motor vehicle and commercial vehicle
inspection programs.

13Voluntary program. . : on e
14Voluntary program.
15Fire apparatus inspection is required by the State Fire Marshall's Office.



The postcrash examination of the firetruck disclosed numerous deficiencies:
The left front tire was underinflated; its rated inflation pressure was 95 psi;
however, it was only inflated to 50 psi. The right rear dual tires were inflated to
45/44 psi; their rated inflation pressure was 85 psi. Further, the firetruck's steering
components were excessively worn. The splined shaft attaching the pitman arm to
the steering gear box was worn, and the ball socket joint where the steering arm
attached to the drag link was excessively worn.

The firetruck's hydraulic brakes also had several deficiencies. SVFD personnel
indicated that before the accident the firetruck would pull to the left during brake
applications. An examination of the brakes revealed that the right front drum was
rusted and the bottom shoe did not make contact with the drum.

As illustrated by the Waterbury, Connecticut, accident, some fire department
maintenance programs do not ensure that fire apparatus are properly maintained.
Further, as illustrated by the Tarrant County, Texas, accident some fire departments
have no maintenance program. Because fire apparatus often stop suddenly,
because they are frequently operated at higher speeds than are conventional
vehicles, and because they are operated under hazardous conditions, it is essential
that they be properly maintained. Therefore, the Safety Board believes that the U.S.
Fire Administration tuseae of the Federal Emergency Management Agency and the
International Association of Fire Chiefs (IAFC) should urge fire departments to
establish vehicle maintenance programs that follow all of the manufacturers service
requirements and schedules.

Fire Apparatus Inspection

Connecticut State Inspection.--Following the Waterbury accident, a mechanical
inspection of the WFD fire apparatus was conducted by the Connecticut Department
of Motor Vehicle (CDMV) Commercial Vehicle Safety Unit. The CDMV indicated that
because of the condition of the brakes, the vehicle failed the safety criteria used in
the commercial vehicle roadside inspection program developed by the Commercial
Motor Carrier Safety Assistance Program (MCSAP) of the Federal Highway
Administration (FHWA).10 After the accident, the Waterbury City Maintenance
Department examined the brakes of the WFD first-line fleet of 9 engines and 5
ladder trucks; 9 of the 14 (64 percent) were withdrawn from service to be repaired.

9The United States Fire Administration maintains offices and conducts programs in the following
areas: fire policy and coordination, firefighter health and safety, fire data and analysis, and fire
prevention and control. The Administration works closely with the Nation's fire service, with fire
service organizations, with Federal, State, and local governments, and with the private sector in
developing and implementing programs aimed at lowering the level of loss of life and property.

10North American Uniform Service Criteria, Commercial Vehicle Safety Alliance, February, 1990,
Out-of-Service. Condition: When any motor vehicle(s) by reason of its mechanical condition or
loading, is determined to be so imminently hazardous as to likely cause an accident or breakdown, or
when such condition(s) would likely contribute to loss of control of the vehicle(s) by the driver, said
vehicle(s) shall be placed out of service. No motor carrier shall require nor shall any person operate
any motor. vehicle declared and marked “out-of-service" until all required repairs have been
satisfactorily completed.

®

®


Figure.2.--Accident vehicle at its final rest position.
(Waterbury Republican American newspaper photograph; Don Cousey, staff
photographer; Tom Kabelka, photo lab.)

The firetruck was eastbound on Farm-to-Market Road 1886 .at a witness-
estimated speed of 45 mph when the driver began negotiating a shallow left curve
on a 6-percent downgrade. The right side tires of the firetruck dropped 5 inches off
the right pavement edge, and the driver steered to the left and lost control of the
vehicle. ‘The firetruck eventually travelled off the pavement on the south side of the
road, dropped 10 feet, and crashed head-on into a.dirt embankment. The firetruck
exploded into flames at impact, and both occupants were killed.

Fire Apparatus Maintenance ‘

WFD vehicle maintenance was performed by the WFD Bureau-of Auto Repairs
(BAR) located in the Waterbury Public Works service yard. The four employees at the
BAR maintained all fire apparatus, firefighting equipment, fire station power
generators, lawn mowers, nonemergency vehicles, and automobiles. ‘The WFD had
42 motorized vehicles including 21 fire apparatus. The WFD mechanics were
required to pass a civil service mechanics test. They received on-the-job training and
brief training seminars from truck dealers and distributors. :


21

CONCLUSIONS
The condition of the rear axle brakes coupled with the use of the wet/dry
switch in the wet position reduced the original braking capability of the
Waterbury, Connecticut, accident vehicle to about 36 percent.
The Waterbury Fire Department Bureau of Auto Repairs did not maintain the
accident vehicle's brakes adequately and did not follow the manufacturer's
recommended service guidelines.

The Waterbury Fire Department Bureau of Auto Repairs did not adhere to its
own policy of servicing a vehicle after 150 hours of service.

The condition of fire apparatus can be improved if these vehicles are subjected
to the level of inspections that commercial vehicles receive through MCSAP.

The use of manual brake limiting valves can diminish fire apparatus stopping
capability.

The use of engine retarders on wet pavement can lead to loss of control.

Firefighters are more likely to avoid ejection and injury if they are restrained.


APPENDIX C

Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas

Utah

Virginia
Washington
West Virginia
Wisconsin
Wyoming

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EXECUTIVE SUMMARY

On May 10, 1990, a 1974 Hahn custom pumper fire engine responding to an
emergency call in Waterbury, Connecticut, ran off the road and hit a large tree when
the driver lost control on a steep downgrade. The fire engine carried five paid
firefighters; two firefighters were fatally injured, one sustained moderate injuries,
and the driver and remaining firefighter sustained only minor injuries. Because the
Safety Board had several other fire truck (apparatus) accidents under investigation
at the time of the Waterbury, Connecticut, accident, it was decided to undertake a
special investigation concerning emergency fire apparatus safety.

The primary safety issues raised by these accidents are the adequacy of fire
department vehicle maintenance programs and State inspection programs, fire
department operating procedures concerning manual brake limiting valves and
engine retarders, and fire apparatus occupant seatbelt use.

Safety recommendations addressing these issues were made to the U.S. Fire
Administration of the Federal Emergency Management Agency, the International
Association of Fire Chiefs, the National Fire Protection Association, and those States
which do not have existing programs in place to periodically inspect fire apparatus.


13

FIRE DEPARTMENT OPERATING PROCEDURES
Accident Information

About 6:50 p.m., on June 9, 1990, engine 381, a 1979 Oren pumper-tanker of
the Long Green Volunteer Fire Company (LGVFC) in Baltimore County, Maryland,
was traveling north on Manor Road responding to an emergency call when the
driver lost control of the vehicle while turning at an intersection. The fire apparatus
rotated 180 degrees and overturned in a ditch. The driver and four firefighters
received minor to no injuries. All of the firefighters were restrained by seatbelts.
The pavement was wet from a previous rain. The driver stated that as he entered the
curve, he was traveling 25 to 30 miles per hour. He took his foot off the gas to slow
the truck, and he “counted on the engaged engine retarder2' to slow him down."
He also stated that "the rear end went very fast, slipped around 180 degrees till | hit
a ditch and flopped over." He indicated that the engine retarder was always left on
and that none of the drivers turned it off.

The driver indicated that he had been driving fire apparatus for 26 years. He
had participated in obstacle course driver training sponsored by the Baltimore
County Fire Department. The LGVFC Chief indicated that the company periodically
received driver training from the Baltimore County Fire Department in whic
participants were taught to leave engine retarders on all the time. It was the LGVFC
practice to have engine retarders on at all times. Additionally, the training officer of
the Baltimore County Fire Department indicated that its drivers were taught to leave
engine retarders on all the time.

Engine Retarders

The Jacobs Manufacturing Company, one of several manufacturers of engine
retarders, warns drivers in its “Professional Driver Techniques and Owner's Manual"
about the dangers of using retarders when they are driving on slippery or wet roads.
The manual states that the driver should not use the retarder until he is sure that his
truck is maintaining traction without its use. Then he can use the lower power
settings on the retarder. Progressively higher power settings should not be used
until it is established that the vehicle is maintaining traction in the lower settings. “If
the tractor drive wheels lock or if there is a fishtail motion, immediately turn off the
master switch and don't turn the Jake Brake [engine retarder] on until road
conditions improve." . .

In the NHTSA booklet entitled "A Professional Truck Driver's Guide on the Use
of Retarders,"22 truck drivers are warned to turn engine retarders off when they are
driving empty trucks or pulling empty trailers on wet pavement or when they are
driving tractors without trailers.

21An engine retarder uses the engine itself to aid in slowing and controlling the vehicle. When
activated, the engine retarder alters the operation of the engine's exhaust so that the engine works
as a power-absorbing air compressor; however, this provides a retarding action only to the drive axle.

22D0T HS 806 675, January 1985.



@

@

15

vehicle is empty or lightly loaded. The placard should also warn
against using the engine retarder to shift gears in these conditions.

The NHTSA responded that the warnings in the booklet "A Professional Truck
Driver's Guide on the Use of Retarders” and in the commercial drivers license (CDL)
“Model Driver's Manual" should reach the truck driving population and eliminate
the need for placarding. The NHTSA was concerned about “driver-compartment
clutter and information overload from an excessive number of lights, buzzers, and
warnings." The NHTSA is investigating the “driver overload issue." Safety
Recommendation .(H-89-38) has been classified as "Open--Acceptable Action."

Also as a result of the Texas and Colorado accidents, the Safety Board issued
recommendations to the Professional Truck Drivers Institute of America, Inc., the
International Brotherhood of Teamsters, the American Trucking Associations, Inc.,
the manufacturers of engine retarders, and the Federal Highway Administration,
recommending that they inform their members of the potential hazards of misusing
engine retarders.and develop training on the proper use of engine retarders. (See
appendix D.) However, no-recommendations were issued to the fire service
community. oo ‘ .

Some of the newer fire apparatus are equipped with engine retarders and
these vehicles have operating characteristics that are similar to those of heavy
commercial trucks. The use of engine retarders on wet pavement can lead to loss of
control. As the Baltimore County, Maryland, accident shows, some fire departments
have policies that directly conflict with the written warnings issued by the
manufacturers of engine retarders. Therefore, the Safety Board believes that the
USFA and the IAFC should inform fire departments nationwide of the potential
hazards of misusing engine retarders and encourage fire departments to establish
operating procedures that are consistent with manufacturers warnings about the
proper use of engine retarders.

Limiting Valves

Following the Waterbury, Connecticut, accident, the front axle limiting valve
was found in the "wet or "slippery-road" position. The driver stated that it had
been raining on and off on the morning of the accident and that the streets were
wet. He had set the valve to the “wet” position earlier that morning before driving
the apparatus. It was WFD practice that when the roads were wet,.the brake
limiting valve was to be switched to the slippery road position.

Hahn "Maintenance-Operating Manual" states that “Putting the lever in the
‘slippery road’ position reduces pressure on the front brakes to half of that on the
rear brakes. The front wheels will have less tendency to slide and steering control is
maintained. Keep the lever in the ‘dry road" position under all normal operatin:
conditions.” The "Model Driver's Manual for Commercial Vehicle Driver Licensing
states:

Some older vehicles (made before 1975) have a front brake limiting
valve and control in the cab. The control is usually marked
“normal" and “slippery.” When you put the control in the
“slippery” position, the limiting valve cuts "normal" air pressure to ..
the front brakes by half. Limiting valves were used to reduce the
chance of the front wheels skidding on slippery surfaces. However,
they actually reduce the stopping power of the vehicle. Front wheel


CONTENTS
EXECUTIVE SUMMARY  ............... 000.0 c eee cece eee e eee eee n eee e eee v
INTRODUCTION ......... 0. cece ccc eee eee eee e nee eeeeeeeeee 1
MAINTENANCE AND INSPECTION
Accident Information ............0 000 c cece cece cece eee lee e ence eee eee 3
Waterbury, Connecticut 3
Tarrant County, Texas 4
Fire Apparatus Maintenance 5
Fire Apparatus Inspection ........ 8
Connecticut State Inspection 8
Texas State Inspection ........... . 9
State Vehicle Inspection Programs. ............ 00. c cece cece eee e eee 9
FIRE DEPARTMENT OPERATING PROCEDURES
Accident Information ............ 2.6 cece cence cece cece e eee e eee eeeee 13
Engine Retarders 13
Limiting Valves ........... 26. c cece cece nen nen eee ener enes 15
OCCUPANT SEATBELT USE
Accident Information .......... 2.6.0.0 c ccc ec eeeeeeee eee eens 17
Catlett, Virginia . 17
Eugene, Oregon. .... 17
Los Angeles, California ........ 17
Gallitzin Township, Pennsylvania 17
Dallas, Texas. ............-0-2- eee eee 18
National Fire Protection Association Standards . 19
Fire Apparatus Occupant Seatbelt Use ......... 19
CONCLUSIONS .........0 0.0 e eee eee eens 21
RECOMMENDATIONS .............. 0.00. cece cece cee cece eee eect eee eeee 23
APPENDIXES
Appendix A--Accident Data) 2.0... 0.0... cece ccc eee cence neces 25
Appendix B--Waterbury, Connecticut, Accident Apparatus Brake Condition 27
Appendix C--Inspection Requirements for Fire Apparatus ................ 29

Appendix C--Status of Previous Recommendations About Engine Retarders 31

iii


27

@ APPENDIX B

WATERBURY, CONNECTICUT, ACCIDENT APPARATUS BRAKE CONDITION

Recommended
maximum stroke
Measured push rod before readjustment
* Air chamber size Slack adjuster stroke (inches) (inches)
Front axle Manual 11/8 13/4
Left 24 Manual 1 . 13/4
Right 24
Rear axle
Left 30/30 Manual 2 2
Right 30/30 Manual 13/4 2

@


NTSB/SIR-91/01 PB91-917001

NATIONAL TRANSPORTATION
SAFETY BOARD

WASHINGTON, D.C. 20594

SPECIAL INVESTIGATION REPORT
EMERGENCY FIRE APPARATUS

ADOPTED: MARCH 19, 1991
NOTATION: 5453

Abstract: For this report, the Safety Board examined 8 separate fire apparatus
accidents and conducted an informal survey of the 50 States and the District of
Columbia to determine their requirements for inspecting fire apparatus. The safety
issues discussed in the report are fire department vehicle maintenance programs and
State inspection programs, fire department operating procedures concerning
manual brake limiting valves and engine retarders, and fire apparatus occupant
seatbelt use. Recommendations concerning these issues were made to the U.S. Fire
Administration of the Federal Emergency Management Agency, the International
Association of Fire Chiefs, the National Fire Protection Association, and those States
which.do not have existing programs in place to periodically inspect fire apparatus.


31

@ APPENDIX D

STATUS OF PREVIOUS RECOMMENDATIONS
ABOUT ENGINE RETARDERS

As a result of the Texas and Colorado directional control accidents,a the Safety
Board issued the following safety recommendations:

--to the Professional Truck Drivers Institute of America, Inc.:
H-89-39

Inform your members of the potential hazards of misusing the
engine retarder and urge your accreditation committee to require
member schools to include training on the proper use of the engine
retarder in their curricula. (Closed --Acceptable Action)

--to the International Brotherhood of Teamsters:
H-89-40

Inform your members of the potential hazards of misusing the
engine retarder and ensure that drivers are adequately trained in
the proper use of the engine and other types of retarders. (Open--
Acceptable Action)

e@ H-89-41

Urge your members to comply with the advisory placards provided
by the engine retarder manufacturers that warn against using the
engine retarder on slippery/wet surfaces when the vehicle is empty
or lightly loaded or that warn against using the engine retarder to
shift gears in these conditions. (Open--Acceptable Action)

--to the American Trucking Associations, Incs.:
H-89-42

Inform your members of the potential hazards of misusing the
engine retarder and urge them to formulate written policies for the
operation of engine retarders and to ensure drivers are trained in
their use. (Closed--Acceptable Action)

@Highway Field Report--" 1981 GMC Astro Jackknife and Loss of Control, near Decatur, Texas," August
( 13, 1985 (NTSB-FTW-85-H-TR38), and Highway Field Report--"1981 Freightliner Jackknife and
Overturn, near Mineral Wells, Texas," April 3, 1986 (NTSB-FTW-86-H-TRO9).

A



10

Among the 18 highway safety program standards issued by the Department of
Transportation were the periodic motor vehicle inspection (PMVI) standards. The
Highway Safety Act of 1966 gave the Secretary of Transportation the authority to
withhold highway construction funds if highway safety program standards were not
met. By 1975, 31 States and the District of Columbia had periodic inspection
programs. However, according to a report! by the U.S. General Accounting Office
(GAO), the Highway Safety Act of 1976 removed the Secretary's authority to
withhold highway construction funds and provided that State safety programs could
be approved without meeting all of the 18 program standards. Ten States repealed
the program as a result of the 1976 Act.2 :

The GAO report states that a 1989 National Highway Traffic Safety
Administration (NHTSA) study3 and other data show that periodic vehicle inspection
programs reduce accident rates. The NHTSA study concluded that periodic
inspection programs reduce the number of poorly maintained vehicles on the
highways, but that available data do not conclusively demonstrate that inspection
programs significantly reduce accident rates.. The GAO took exception to this
conclusion and reexamined the eight studies quoted in the NHTSA study. The GAO
‘ound that: .

Taken together, the studies discussed in NHTSA‘s report as well as
-several other studies identified by: GAO indicated that inspection
programs reduce accident rates. These studies included estimates of
accident reduction ranging from less.than 1 percent to as high as.
27 percent. The actual magnitude of the reduction is unknown. GAO
agrees with NHTSA that all of the studies had limitations either of
scope, age, or methodological completeness. Thus, while the large
majority of studies point to a safety benefit from inspection
programs, they do not provide a reliable basis for judging how much
effect the programs have on accident rates.4

Asa result of the 1990 report, the GAO recommended that:

..the Secretary of Transportation direct NHTSA to support state
periodic motor vehicle inspection programs through such actions as
(1) sponsoring research, (2) assisting inspection states to share their
experiences and adapt to changing automotive technology, and (3)
promoting public awareness of the need to properly maintain the
safety-critical components of vehicles.

‘Motor Vehicle Safety, “NHTSA [National Highway Traffic Safety Administration] Should Resume Its
Support of State Periodic Inspection Programs,” Report to the Chairman, Subcommittee on Oversight
and Investigations, House Committee on Energy and Commerce, United States General Accounting
Office, (GAO/RCED-90-175), July 1990. . . .

2Those States that repealed PMV programs after the 1976 legislation are listed with the dates of start
and repeal: Colorado (1937-1981), New Mexico (1953-1977), Georgia (1965-1982), Wyoming
(1967-1977), Florida (1968-1981), Idaho (1968-1976), Kentucky (1968-1978), South Dakota
(1968-1979), Indiana (1969-1980), Nebraska (1969-1982) :

3"Study of the Effectiveness of State Motor Vehicle Inspection Programs,” NHTSA, (Washington, D.C.,
August 1989). . Do "

4GAO, executive summary, p.5.


14

The “Model Driver's. Manual for Commercial Vehicle Driver Licensing"23 also
addresses engine retarders and states:

Some vehicles have "retarders." Retarders help slow a vehicle,
reducing the need for using your brakes. They reduce brake wear
and give you another way to slow down. There are many types of
retarders (exhaust, engine, hydraulic, electric). All retarders can be
turned on or off by the driver. On some the retarding power can be
adjusted. When turned "on" retarders apply their braking power (to
the drive wheels only) whenever you let up on the accelerator pedal
all the way.

Caution: When your drive wheels have poor traction, the retarder
may cause them to skid. Therefore you should turn the retarder off
whenever the road is wet, icy or snow covered.

In 1982 and 1983, the NHTSA sponsored research that was done by the
Transportation Research Institute of the University of Michigan.24 The research
explored. the influence of retarder torque on directional control on slippery
pavements. In summary, the study indicates that drivers of retarder-equipped
vehicles should be informed that they may avoid potential control problems by
turning off their retarders when they are operating either empty or lightly loaded
vehicles on roads that are either icy or slippery. The experimental portion of the
research was performed by a test driver who had experience in heavy-truck braking
experiments on slippery surfaces. In the experiment, this driver could not recover
from the rapid jackknifes that occurred on slippery surfaces when he was turning an
empty vehicle while decelerating with the engine retarder.

In 1985 and 1986, the Safety Board investigated accidents in Texas and
Colorado2s in which heavy trucks lost directional control due to the misuse of engine
retarders. The drivers of the trucks did not have manufacturers’ operating manuals,
and-the motor carriers had not established operating procedures that were
consistent with the manufacturers’. warnings about the proper use of engine
retarders.

. ° As-a result of these investigations, the Safety Board recommended that the
National Highway Traffic Safety Administration (NHTSA):

H-89-38
+. Require the installation of a permanently affixed placard in the

interior of new truck tractors equipped with an engine retarder to
warn against using the retarder on slippery/wet surfaces when the

23U.S. DOT, Federal Highway Administration Publication No. FHWA-MC-89-051, dated January 31,
1989.

24”Retarders for Heavy Vehicles: Phase Ill Experimentation and Analysis; Performance, Brake Savings,
and Vehicle Stability" (DOT HS 8006 672). :

25Highway Field Report--"1981 GMC Astro Jackknife and Loss’ of Control, near Decatur, Texas,"
August 13,1985 (NTSB-FTW-85-H-TR38), and Highway Field Report--" 1981 Freightliner Jackknife and
Overturn, near Mineral Wells, Texas," April 3, 1986 (NTSB-FTW-86-H-TRO9).