By Michael Grabell and Sudeep Reddy
The Dallas Morning News
Copyright 2006 The Dallas Morning News
WASHINGTON, D.C. — Bus fires similar to the one that ultimately killed 23 nursing home patients evacuating ahead of Hurricane Rita last year happen at least six times a day in the U.S., and buses often lack the equipment for drivers to fight them, federal safety officials said Tuesday.
The lack of data on bus fires was a key focus on the first day of a National Transportation Safety Board public hearing into the causes of the Sept. 23 fire outside Wilmer.
“We have been very lucky that there haven’t been more injuries and fatalities,” said NTSB member Kitty Higgins, who led Tuesday’s hearing. “It’s a problem we don’t have the data on. There’s a big issue here that we’re just beginning to understand.”
The board plans to issue recommendations by early next year to prevent similar accidents.
NTSB investigators confirmed that the fire started when poorly lubricated bearings in the right rear wheel heated up, igniting the tire and spreading the fire into the cabin, where 11 oxygen bottles were stored for the elderly passengers. Many patients were too frail to escape and remained seated as five of the canisters ruptured and melted, accelerating the fire.
While most of the bus fires end without injuries, the Sept. 23 blaze — which injured 14 other patients on board — became the deadliest U.S. transportation accident since a 2001 plane crash in New York.
In the two-day hearing, the NTSB is examining how to keep dangerous buses off the road, how nursing homes should prepare for evacuations, the lack of broker regulations and how buses should be designed to transport people with special needs. Such hearings are generally reserved for major plane disasters, and this week’s hearing is the first to address bus safety in more than six years.
Several flaws
So far, the NTSB investigation has found a number of problems.
The patients were being evacuated from the Brighton Gardens of Bellaire nursing home, near Houston, on an unregistered bus by a driver who sneaked into the U.S. from Mexico and couldn’t speak English well enough to talk to passengers.
The company he worked for had a federal driver-safety rating worse than 97 percent of all bus and truck companies. The nursing home did not have detailed transportation plans for an evacuation. Even the 5-pound fire extinguisher on board — the basic requirement — was insufficient to handle such a fire, officials said.
“I have a 5-pound fire extinguisher in my kitchen,” Ms. Higgins said. “That is not a real big piece of firefighting equipment.”
The board heard testimony about new fire detection and suppression systems designed to alert drivers to excessive heat and suppress a fire long enough for passengers to get off the bus.
Emmett Bevins of Amerex, a fire suppression company, said that his corporation has tested such systems — including in Dallas Area Rapid Transit buses — but that no system has been designed for tire fires.
“There’s all kind of debris being thrown around in there — mud, road tar,” he said. “We never could make a system that could survive in a wheel well.”
The federal government does not keep comprehensive data on bus fires because they’re not always classified as accidents.
One analysis of national fire data found that 2,200 charter or school buses catch fire each year, an average of six a day. The vast majority are due to mechanical or equipment failures, said Marty Ahrens of the National Fire Protection Association. And many fires never get reported.
NTSB investigators’ reports released Tuesday provided some new details about what might have contributed to the fire near Wilmer and the number of fatalities.
The driver, Juan Robles Gutierrez, couldn’t speak English well enough to give passengers instructions, investigators said. Federal regulations say bus drivers must be able to read road signs, communicate with passengers and answer questions from police.
But the investigators noted that states have no obligation to verify English proficiency when they issue a commercial driver’s license. Federal bus-safety agents and Texas state troopers said they have been directed not to order drivers off the road for failing to speak English.
Failure to speak English has been a problem in several bus and truck accidents, investigators said, when drivers couldn’t tell passengers to evacuate or tell first responders about hazardous materials on board.
Though investigators did not say the driver’s health contributed to the accident, reports noted that Mr. Robles had medical problems that should have prevented him from operating a bus.
Mr. Robles told investigators that he had Type 2 diabetes, but his Mexican driver’s license indicated that he did not.
In March 2005, a doctor conducting a U.S. Transportation Department physical refused to issue Mr. Robles a medical certificate because of the diabetes diagnosis. He asked him to take tests showing that his diabetes was controlled, but Mr. Robles failed to report for them.
NTSB investigators also noted that Sunrise Senior Living, the company that runs Brighton Gardens, did not contact the Texas Building and Procurement Commission, which was coordinating the Hurricane Rita evacuation. Instead, Sunrise representatives called a Chicago-based online bus broker, which they found in a Google search while trying to transport patients during the Hurricane Katrina evacuation.
Sunrise had no problems with the broker, The BusBank, during the Katrina evacuation. But for the Rita evacuation, The BusBank said it didn’t have any buses available from its usual pool. The broker called back and said the company had located two buses. Sunrise employees told investigators they were unaware that The BusBank had contracted with Global Limo of Pharr, Texas.
Delayed response
The NTSB reports also pointed to problems with local emergency preparedness. According to investigators, firefighter and paramedic response was delayed because initial 911 calls gave an inaccurate accident location; traffic was backed up; Wilmer had only one dispatcher on duty; and the two firefighters-emergency medical technicians at the Wilmer firehouse had to wait for other volunteers to show up before departing.
In addition, Dallas County has no standard procedures for handling mass casualties. A plan has been formulated, but half the cities in the county — including Dallas — have not signed on, according to the reports.
The accident came as a frenzied evacuation clogged Interstate 45 with cars, even as all lanes on much of the highway were changed to northbound.
According to NTSB reports, at 3:15 a.m., after the bus had been on the road for 12 hours, the wheel locked up, leaving tire marks on the road. A forensic tire expert said the marks indicated the tire was inflated when the first marks were left, indicating that a blowout wasn’t the main problem.
A mechanic changed the tire but didn’t notice the tire marks or the flattened wheel rim. And no one told him of any other problem.
With a new tire, the bus continued toward Dallas. Over the next two hours, the poorly lubricated bearings were grinding, becoming flattened and welding together — a process that requires temperatures of more than 2,400 degrees Fahrenheit. Some bearings broke off completely.
At 6:04 a.m., Ferris volunteer firefighters were called out to fight a grass fire on the side of the highway 3.2 miles from the accident site. Investigators later found two small metal objects resembling wheel bearings from the tag axle.
Electricians Jason Saulsbury and Drew Wood were heading to work just after 6 a.m. when they saw flames from the bus fire.
They tried opening or breaking escape windows to pull passengers out, they said at Tuesday’s hearing. They entered the bus three times before exploding oxygen canisters onboard accelerated the fire and stopped them.
The fire progressed quickly. “It didn’t take long at all before it was engulfed with dark, thick smoke, and you couldn’t even catch your breath,” Mr. Wood said.
Ms. Higgins, the NTSB member, said victims’ relatives were following the proceedings to understand what caused the tragedy.
“Nothing can change the unfortunate outcome of such a tremendous loss of life,” Ms. Higgins said. “But what we can do is find out exactly what happened in this accident, understand the dimensions of the problem and make very specific recommendations ... to make sure that these fires are prevented in the future.”