Analysis of Texas Bus Fire: Lessons Learned for Victoria

Gemma ReadRay Misa

Elizabeth Grey

22 January 2013

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Overview of presentation

The presentation covers four topics:

1.Bus fires in Australia

2.The Texas bus fire

3.Factors contributing to the fire & its outcome

4.Implications for Victoria

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• Approximately 70 bus / coach fires per year

• Steady annual increase of 15-20%

• Increase coincides with introduction of buses designed for tighter emissions standards and noise limits (OTSI report)

• Most fires begin in the engine bay (OTSI report)

• No national database of occurrences

Bus fires in Australia

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• Total of 32 fires over three years – average 10 per year• No injuries resulted• Moving average indicates increase

Bus fires in Victoria

Data source: TSV (2013) Quarterly incident statistics for BUS 2013 – 3rd Quarter

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• Hurricane Rita evacuation • Bus company contracted to

transport assisted living home residents

• 44 passengers on board• Fire began following wheel

bearing failure• Spread quickly, engulfing vehicle

in flames• 23 fatalities, 2 serious injuries• Systemic investigation by NTSB

The Texas bus fire

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• 5:00am – Driver departs with motorcoach• 11:00am – Driver arrives at the assisted living home• 1:30pm – Passenger loading begins• 3:30pm – Bus departs• 4:00pm – Bus stops, nurses retrieve two oxygen cylinders• 3:15am (the following morning) - Right-side tag axle wheel locks, tyre

blows out. Vehicle is moved to safe location• 4:30am – Police & tow truck mechanic arrive. Tyre is changed• 5:00am – Bus continues• 6:00am –

• Motorist notices rear tyre glowing red. Informs driver• Pulls off road. Driver exits vehicle, observes wheel well on fire• Tries to extinguish, cannot unlatch extinguisher• Nurses & bystanders evacuate passengers until smoke too thick & explosions

• 6:24am – Firefighters arrive. Bus is engulfed in flames

Timeline of events

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Systemic investigations

• Identify the conditions and systemic failures that led to an event

• Considers the whole organisation• Not just “what happened”• See the event as a symptom

• Looks upstream• Past decisions by management

• Worker competence & support systems

• Supervision, resourcing, etc.

• Assumes that• Human error is inevitable

• Error is a consequence

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A structured framework for capturing & categorising the systemic contributors to transport safety occurrences

The Contributing Factors Framework

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• The contributing factors framework is applied after a transport safety occurrence is investigated through a systemic investigation

• The framework is applied using a coding form for which a template is available

• The coding form summarises the investigation report

Applying the Contributing Factors Framework

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• When multiple coding forms have been completed, data can be analysed across occurrences

• For example, data may show that the majority of occurrences involved issues associated with:• personal factors (such as fatigue)• task demands (such as high workload)• people management (such as lack of supervision)• organisational management (such as policy)• external organisational influences (such as regulation)

Outcomes of the Contributing Factors Framework

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• Workshop format• Representatives from:

• Regulator: TSV’s Bus & Human Factors teams• Industry: McKenzies Tourist Services• Investigator: Office of the Chief Investigator

• Process• Reviewed investigation findings• Identified contributing factors• Selected appropriate codes• Discussed implications

Applying the framework to the Texas bus fire

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• Four separate events were identified, with some different factors contributing to each:

1. The tag axle wheel locking, tyre dragging and blow out

2. Tyre fire

3. Uncontrolled fire

4. Failure to evacuate all passengers

Events identified within the occurrence

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Factors contributing to the tag axle wheel locking

Technical failures Local conditions Organisational factors

Right-side tag axle wheel bearing assembly lacked sufficient lubrication(coded as Wheels & tyres)

Failure to conduct pre & post trip inspections (coded as Absent procedure)

Lack of general maintenance (coded as lack of Compliance)

Absence of warning in maintenance manual (coded as Industry standards / guidance)

Regulations were inadequate (coded as Regulatory standards / guidance)

Lack of concern for safety management controls (coded as Organisational policy)

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Factors contributing to the tyre fire

Technical failures Local conditions Organisational factors

Right-side tag axle wheel bearing assembly lacked sufficient lubrication(coded as Wheels & tyres)

Failure to conduct pre & post trip inspections (coded as Absent procedure)

Lack of general maintenance (coded as lack of Compliance)

Absence of warning in maintenance manual (coded as Industry standards / guidance)

Regulations were inadequate (coded as Regulatory standards / guidance)

Lack of concern for safety management controls (coded as Organisational policy)

Regulator failed to identify unsafe motor carrier (coded as Regulatory activities)

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Factors contributing to the uncontrolled fire

Technical failures Local conditions Organisational factors

None Newspapers were used to cover windows (coded as Housekeeping)

The exterior of motorcoach had not been fire-hardened (coded as Equipment, plant & infrastructure)

Passenger compartment not designed with fire / smoke retardant material (coded as Equipment, plant & infrastructure)

Proximity of combustible materials including fuel – accelerated the fire (coded as Equipment, plant & infrastructure)

Regulations did not require fire-hardening (coded as Regulatory standards / guidance)

Failure to act on bus fire data & recommendations (coded as Government influences)

Standards did not mandate an on-board fire detection system(coded as Industry standards / guidance)

16Factors contributing to the failure to evacuate all passengers

Technical failures Local conditions Organisational factors

None The exterior of motorcoach had not been fire-hardened (coded as Equipment, plant & infrastructure)

Passenger compartment not designed with fire / smoke retardant material (coded as Equipment, plant & infrastructure)

Proximity of combustible materials including fuel – accelerated the fire (coded as Equipment, plant & infrastructure)

Lack of vehicle evacuation capability (coded as Equipment, plant & infrastructure)

Large number of mobility impaired passengers (coded as Physical limitations)

Regulations did not require fire-hardening (coded as Regulatory standards / guidance)

Failure to act on bus fire data & recommendations (coded as Government influences)

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Safety issues found to be present, but that did not contribute to the occurrence included:

•Driver was fatigued at the time of the fire (coded as Fatigue / alertness)

•Driver was non-English speaking (coded as Communication skills)

•Partially pressurised aluminium oxygen cylinders were carried in the vehicle (coded as Risk management)

•Delay in calling emergency services, with erroneous location information provided (coded as Information management)

•Emergency service dispatchers were understaffed (coded as Rostering / scheduling)

Non-contributing safety issues

18Implications & opportunities for the Victorian bus industry

Finding Implications Opportunities

Lack of routine maintenance inspections

• Bus Safety Act requires higher standard of maintenance

None

Large number of mobility impaired passengers could not be evacuated

• Legislation requires that risks be reduced SFAIRP

Review of:•Management of passengers with special needs•Emergency procedures•Emergency egress capabilities

Partially pressurised aluminium oxygen cylinders were carried in the vehicle

• Legislation requires that risks be reduced SFAIRP

• Carriage of dangerous goods requirements

Review of management of potentially hazardous cargo

19Implications & opportunities for the Victorian bus industry (continued)

Finding Implications Opportunities

Vehicle design did not suppress fire

• Australian design rules (ADRs) have few requirements in relation to fire safety

Review ADRs in relation to:•Use of fire retardant and non-toxic materials•Passive fire safety through design•New technologies for fire detection & suppression

Regulations were inadequate

• Bus Safety Act requires risk-based approach

• None

Failure to act on bus fire data and recommendations

• State-based data collection & reporting, no national system

• Multiple parties involved in managing bus fire risk

• Development of a national database, including contributing factors, to assist to understand risk

• Bus Industry Confederation developing bus fire advisory

• Sharing and learning from local and international events

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• Fire is a key risk for the bus industry

• The risk may be increasing

• There are opportunities for reducing risk at a strategic and individual bus operator level

• Individual operators need to consider the implications for their operations and ensure they are managing the risk

Conclusions

Questions?

We would like to acknowledge the workshop participants for their input. Thanks to:

Brad Sanders (McKenzies)

Sri Ranasingha (OCI)

Angela Barkho (TSV)

Shaun Rodenburg (TSV)

Andrew Chlebica (TSV)