Analysis of Texas Bus Fire: Lessons Learned for Victoria

1. Analysis of Texas Bus Fire: Lessons Learned for Victoria Gemma ReadRay Misa Elizabeth Grey 22 January 2013

2. Overview of presentation The presentation covers four topics: • Bus fires in Australia • The Texas bus fire • Factors contributing to the fire & its outcome • Implications for Victoria

3. 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

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

5. 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

6. 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 – • 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

7. 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

8. The Contributing Factors Framework A structured framework for capturing & categorising the systemic contributors to transport safety occurrences

9. 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

10. 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)

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

12. Events identified within the occurrence • Four separate events were identified, with some different factors contributing to each: • The tag axle wheel locking, tyre dragging and blow out • Tyre fire • Uncontrolled fire • Failure to evacuate all passengers

13. Factors contributing to the tag axle wheel locking

14. Factors contributing to the tyre fire

15. Factors contributing to the uncontrolled fire

16. Factors contributing to the failure to evacuate all passengers

17. 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)

18. Implications & opportunities for the Victorian bus industry

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

20. 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

21. 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)