Analysis of Texas Bus Fire:
Lessons Learned for Victoria
Gemma Read
Ray Misa
Elizabeth Grey
22 January 2013
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
2
Bus fires in Australia
• 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
3
4
Bus fires in Victoria
• Total of 32 fires over three years – average 10 per year
• No injuries resulted
• Moving average indicates increase
Data source: TSV (2013) Quarterly incident
statistics for BUS 2013 – 3rd Quarter
The Texas bus fire
• 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
5
Timeline of events
•
•
•
•
•
•
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 –
•
•
•
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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
6
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
7
The Contributing Factors Framework
A structured framework for
capturing & categorising the
systemic contributors to
transport safety occurrences
8
Applying the Contributing Factors Framework
• 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
9
Outcomes of the Contributing Factors Framework
• 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)
10
Applying the framework to the Texas bus fire
• Workshop format
• Representatives from:
• Regulator: TSV’s Bus & Human Factors teams
• Industry: McKenzies Tourist Services
• Investigator: Office of the Chief Investigator
• Process
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•
•
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Reviewed investigation findings
Identified contributing factors
Selected appropriate codes
Discussed implications
11
Events identified within the occurrence
• 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
12
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)
Absence of warning in
maintenance manual (coded
as Industry standards /
guidance)
Lack of general maintenance
(coded as lack of Compliance)
Regulations were inadequate
(coded as Regulatory
standards / guidance)
Lack of concern for safety
management controls (coded
as Organisational policy)
13
14
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)
Absence of warning in
maintenance manual (coded
as Industry standards /
guidance)
Lack of general maintenance
(coded as lack of
Compliance)
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)
Factors contributing to the uncontrolled fire
Technical failures
Local conditions
Organisational factors
None
Newspapers were used to cover
windows (coded as
Housekeeping)
Regulations did not require
fire-hardening (coded as
Regulatory standards /
guidance)
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)
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)
15
Factors 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)
Regulations did not require
fire-hardening (coded as
Regulatory standards /
guidance)
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)
Failure to act on bus fire data
& recommendations (coded as
Government influences)
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Non-contributing safety issues
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)
17
Implications & 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
Review of:
risks be reduced SFAIRP • Management of
passengers with special
needs
• Emergency procedures
• Emergency egress
capabilities
Partially pressurised
•
aluminium oxygen
cylinders were carried in •
the vehicle
Legislation requires that
Review of management of
risks be reduced SFAIRP potentially hazardous cargo
Carriage of dangerous
goods requirements
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Implications & 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 nontoxic materials
• Passive fire safety through
design
• New technologies for fire
detection & suppression
Regulations were
inadequate
•
Bus Safety Act requires
risk-based approach
•
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
•
•
•
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None
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
Conclusions
• 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
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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)