PTSB SPECIAL STUDY BUS FIRE ANALYSIS - PTSB INVESTIGATIONS 2002 thru 2006

Public Transportation Safety Board Staff Passenger Carrier Safety Bureau

December 8, 2008

Executive Summary
In 2007, the New York State Public Transportation Safety Board (PTSB) conducted a review of the causes of previously investigated bus fires over a five year period (2002-2006). The review included 120 fire investigations conducted by PTSB staff. This report addresses significant trends and, through the cooperation of an industry based committee1, provides recommendations to prevent future, similar bus fires.

Although rider ship numbers are similar in 2002 and 2006, a 3.5% decrease in rider ship was experienced in 2004. PTSB bus fires experienced a spike in the number of occurrences in 2004, representing 41% of the total yearly investigations (34 fires out of 83 investigations).

--------------------------------1. An industry based review committee was formed to provide proper co ntext to the report and recommend ations. The committee consisted of staff from MTA-NYCT (Steve Vidal, Charles Dagis, Scott We instein), CDTA (Tom M ckie), MTA- IG and PT SB B oard M ember (Barry K luger), NYSD OT (Ron Ep stein), and PT SB (John Fabian). Special thanks are given to these ind ividuals, and to Steve Trudell and M att Sok ol, for their time and effort for pr ovid ing statistical information for this pro ject.

In summary, the review identified trends indicating 59% of bus fires are caused by either nonmaintenance random failures or non-maintenance manufacture design. An additional 28% were the result of transit systems employees, followed by 13% unknown causes. Known sources of fires were tied to two specific areas: electrical failures and high pressure lines or connection failures. Electrical, including maintained and non-maintained equipment, accounts for 60 of the 120 fires, or 50% of all fires in the study period. The most frequently involved manufacturer was Orion, represented in 59 of 120 bus fires (50%), who also represents approximately 40% of the statewide fleet of buses in service. The most common age of the bus involved in a fire is approximately 6 years old.

Report Recommendation Highlights

The review of bus fires from 2002-2006 has revealed that although most fires have been attributed to causes deemed either non-maintenance or random component failures, there is a great deal transit systems can continue to do to prevent bus fire events. Human failures still occur in areas such as : - improper repairs - neglect - lack of training - lack of supervisory oversight - failure to detect - lack of skill - bus operator, maintainer, or supervisor - improper policies and procedures In order to reduce bus fires, transit systems must determine when pre-ignition conditions exist that can be corrected during the life expectancy of the bus. These conditions can exist from the very first day the vehicle is on the property to the last month of its life span. Specific Action by Responsibility: Statewide Industry (in cooperation with NYSDOT) PTSBFR08-1 - develop and task an industry based committee to provide feedback, support, information, and direction towards minimum procurement standards and recommendations for future bus purchases aimed at reducing bus fires PTSBFR08-2 -develop a statewide database of information on fires that includes causes of fires, tracking related parts (by model, serial number and manufacture), evaluation of suppression system effectiveness, and statewide recommendations to bus systems for improved performance ii

PTSBFR08-3 - develop interface with industry partners such as NYSDOT, PTSB, APTA, NFPA, bus manufacturers, suppression system manufacturers, component manufacturers, and others involved in the prevention of bus fires All Bus Transportation Systems (under PTSB jurisdiction): Management PTSBFR08-5 - provide direction and oversight thru policies, procedures, and training to reduce the occurrence of bus fires throughout the system, incorporating at minimum, the following recommendations:

Maintenance PTSBFR08-9 - keep ignition points protected, covered, clean, and other debris away; engines clean of grease, oil, and other fuel sources for fires -train technicians to properly diagnose a dangerous condition and effect a proper repair; properly identifying and repairing leaking high pressure lines and chafing electrical wiring, the two most common sources of fires - eliminate all areas of water intrusion -understand new technology, such as particulate trap regeneration systems that operate at very high temperatures and require special training to properly perform work on these components as well as updating PMI forms and procedures as needed - ensure buses that are overhauled or rehabilitated due to high mileage or hard service life are given quality control inspections in areas where electrical cables, high pressure lines and connections, junction boxes, and other retrofit components are installed - use of quality OEM or equal replacement parts is highly recommended - use quality control inspectors or supervisors to ensure work performed on parts frequently related to fires are inspected during and at the completion of the task especially such areas as starters, generators/alternators, air conditioning units, wheel bearings, brakes, exhaust heat shields, turbo charger heat shields, battery cables, and other related components

PTSBFR08-12

PTSBFR08-13 PTSBFR08-14

PTSBFR08-17

PTSBFR08-18

PTSBFR08-19

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Procurement/Rebuilds PTSBFR08-20 - establish procurement standards requiring quality parts and vehicle components, along with fire resistant materials, and fire suppression systems

Operations PTSBFR08-23 -ensure training of bus operators includes fire safety procedures and emphasizes the importance of passenger safety and immediate evacuation of the bus in a safe location, securement the bus along with dispatch notification -ensure bus operator training and annual refresher include early detection and symptoms of potential fires such as leaking fluids (engine and wheels), low air in tires (especially duals), changes in gauge readings on instrument panel, loss of drive power, smell of overheating conditions, poor brake performance, lack of turbo power, etc

PTSBFR08-24

Safety PTSBFR08-26 - conduct safety oversight thru competent investigations for causes of fire incidents, disseminating the information, and improving the policies and procedures based on what was learned - conduct ongoing quality control inspections to ensure the safety of buses in service - ensure bus operators are conducting proper pre/post trip inspections as a critical aid for the mechanics in order to allow them to perform their jobs properly

PTSBFR08-27

PTSBFR08-28

Further study should be conducted beyond the availability of information found within the 120 investigative reports of the PTSB throughout this five year period of history. As additional high tech, integrated technology is adopted into the day to day operation of transit systems, efficiency to operate and ability to detect the inefficiency of safe operation of vehicles must grow continuously. In closing, the potential for catastrophic events that include human loss as a result of a bus fire makes it essential for government, industry and manufacturing to work cooperatively to ensure the safety of all passengers, employees and the traveling public. The PTSB has remained vigilant, conducting investigations into causes and sources of bus fires for the past 24 years. Although the incidence of injury has been extremely low in New York, other locations in the US and the world have experienced horrific losses due to bus fires, demanding our continual oversight of our systems here in New York State. The review of bus fires from 2002-2006 has revealed that although most fires have been attributed to causes deemed non-maintenance, random component failures, there is a great deal transit systems can continue to do in support of reducing bus fire events.

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Bus Fire Analysis: PTSB Investigations 2002 thru 2006

INDEX
Executive Summary .........................................................................................................................i Introduction .....................................................................................................................................3 PTSB Fire Criteria ..........................................................................................................................4 PTSB Criteria Notifications of Bus Fires 2002-2006 .....................................................................4 Table 2 - PTSB 2002-2006 Criteria Bus Fires ................................................................................4 Data of Fires Investigated between 2002- 2006 ..............................................................................5 Table 3 - 2002-2006 Comparison of Fires by Company .................................................................5 Table 4 - 2002-2006 Comparison of Fire Rate per Property............................................................6 Table 5- 2002-2006 Comparison of Fires by Month ......................................................................7 Table 6 - 2002-2006 Comparison of Fires by Week .......................................................................7 Table 7 - 2002-2006 Comparison of Fires by Day ..........................................................................7 Table 8 - 2002-2006 Bus Fires by Origin ......................................................................................8 Table 9 - 2002-2006 Bus Fires by Cause ........................................................................................9 Table 10 - 2002-2006 Bus Fires by Source ...................................................................................11 Table 11 - 2002-2006 Bus Fires by Condensed Source ................................................................11 Table 12 - 2002-2006 Bus Fires by Age of Bus... .........................................................................12 Table 13 - 2002-2006 Bus Fires by Manufacturer.........................................................................13 Table 14 - 2002-2006 Orion Bus Fires by Source ........................................................................14 Table 15- 2006 NYS Percentage of Manufacturer by National Fleet............................................14 Table 16- 2006 Composition of Fleet for CDTA, LIB, NFTA and NYCT ..................................15 Page 1

Table 17 - 2006 NYS Percentage of Revenue Miles by Manufacture ..........................................15 Table 18 - 2006 NYS Revenue Miles by Manufacturer for CDTA, LIB, NFTA and NYCT .......16 Findings..........................................................................................................................................17 Recommendations .........................................................................................................................19 Appendices ....................................................................................................................................23

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Introduction
The Public Transportation Safety Board, under legislative authority, has been investigating bus fires since 1984. Three hundred and forty four fires were reported and investigated by PTSB bus staff during this 23 year period (1984-2007). Although there have been significant property damage losses, there have been very few injuries associated with these events, mostly from smoke inhalation and those injuries have been minor. The potential for catastrophic human loss is present at most if not all bus fire events that occur, whether they are happening in a congested city environment such as New York City or in a rural atmosphere like Essex County. In the Summer of 2007, the PTSB Board requested staff to review previous PTSB fire investigations conducted during a 5 year period (2002-2006), a total of 120 events. A scope of study was presented to the Board in July, 2007 outlining the areas to be analyzed for trends. Those topics included the entity responsible for the operation and maintenance of the bus, bus manufacture and age, geographic location of the event, cause of the fire, location of the fire on the bus, type of fire involved, auto extinguishing features, related injuries, and a review of other bus fire data sources. The conclusion of the report was to address significant trends and provide recommendations to prevent future bus fire re-occurrences.

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PTSB Fire Criteria The PTSB Rules and Regulations, Section 990.10(a)(3), classify a bus fire as a mechanical failure accident and requires notification to the PTSB staff of any fire that occurs in revenue service that requires passenger evacuation and response by a fire department regardless of whether or not injuries were incurred. The required reporting system under Section 990.10(b) establishes 90 minutes to report the incident to PTSB staff. Written notice is required within 48 hours unless otherwise specified by staff. PTSB staff are dispatched to investigate the incident and report the findings to the Board. PTSB Criteria Notifications of Bus Fires 2002-2006 Within the 5 year period selected for the database for this review (2002-2006), the PTSB staff has investigated 120 PTSB criteria bus fires. These events have all occurred involving recipients of Statewide Mass Transportation Operating Assistance (STOA) money. Receipt of STOA places the system under the jurisdiction of the PTSB. Each event is assigned an investigator and tracked by a case number. The investigation generally includes an inspection of the scene and the bus, an interview with the driver and any witnesses, and a full review of all records including preventive and corrective maintenance, pre and post trip inspections, recalls or retrofits, and any relative manufacture information. The goal of the investigation is to determine the cause of the fire and related fueling sources, and to ensure that the company has taken the appropriate measures to prevent other buses from the same fate. Table 2

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Data of Fires Investigated between 2002- 2006

Fire incidents are reported under the definition of mechanical failure accidents. Reviewing a comparison of criteria accidents over this period of time, fire investigations have occurred at a low of 17% in 2002, to a high of 40% in 2004. Looking at a five year average, fires represent 28% of the yearly number of PTSB investigations. Distribution of fires reported by PTSB bus systems from 2002 through 2006 The distribution of bus fires by property during the study period, 2002 through 2006, includes 25 bus systems located throughout NYS; 61% upstate and 39% downstate (12 county metro region). It includes authority 30% (7 of 25), municipality 26% (6 of 25) and private 44% (10 of 25) operated systems. The most number of fires investigated associated with an individual bus system involved the MTA-NYCT with 51 occurrences, and the least (not including those with no fires) was one incident involving seven different systems; TCAT, City of Oneonta, Intercounty Motor Coach, Greater Glens Falls Transit, Centro, Jamiaca Buses (now MTA Bus Co), Dutchess County LOOP, Chemung Tranist, and Adirondack Transit Lines. The remaining 95 systems did not report any fires.

Table 3 During the past five years, 85% or 102 of the 120 fires occurred with a bus operated by a public Page 5

authority. Although there are only 6 public authority systems operating within the State; MTA (MTA NYCT, MTA Bus Company, MTA Long Island Bus), CDTA, Centro, RGRTA, and NFTA, data includes NJT (New Jersey Transit) who also operates buses in NY. These authorities operate a total of approximately 8,840 buses. This represents about 81% of the 11,000 buses operated under the jurisdiction of the PTSB statewide. The remaining 7% and 13% are operated by municipal and private carriers respectively. The correlation of public verses private system type does not appear to reveal any unusual trends. Large systems operate bus fleets in excess of 200 buses. Medium systems operate from 25 to 199 buses in their fleet and small systems operate less than 25 vehicles. On average the large systems group experience 21.1 fires yearly (106 total fires), the medium group 1.6 fires per year (8 total fires) and the small groups average 1.2 fires per year (6 total fires). Due to the vast differences in fleet sizes and revenue miles performed by each system statewide, the following table compares the number of buses in the fleet, the number of revenue miles traveled during the study period and the number of bus fires experienced during the 5 year study period. Table provides a normalized bus fire rate of occurrence for the period 2002-2006.

Table 4

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Table 5.

The review of fire incidences by month over the past 5 year period, shows a random distribution of occurrences with a high of 15 in September and a low of 7 in December. The average number of fires in a month on a yearly bases is 2.

Table 6 The distribution of fires throughout the week on a 5 year average reveals the lowest 5 year average is Sunday at 5.8%, followed by Saturday at 9.1% (weekend rates). This compares logically with the rest of the weekday averages at 85%, given the majority of peak service is provided during the weekday.

Table 7 Following the same trend as the fires occurring by day of the week, a logical trend exists comparing fire occurrences with the highest and heaviest passenger service times of the day (peak service); 7 - 10 am and 3 - 5pm. During the hours of 2 - 4 am, there were no fires reported.

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A review of bus fires by origin of the fire shows 70% of the 120 fires occurred in the area of the engine compartment. The area includes the engine and all components, transmission, exhaust, wiring, hoses, fluids, turbo charger, etc, but does not include the AC unit (listed separately). The other 30% of fires originated in six other areas as described below. AC Unit: includes the air conditioning unit, fan, motor, electrical and fluid lines, and belts. Undercarriage: includes the area underneath the bus, fuel tank, hoses, air lines, wheel bearings, air bags, suspension components, steering components, booster heaters, and air dryers. Tires: includes tires, wheels, seals, lugs, etc. Roof: includes top extension of exhaust (including exhaust after treatment devices), lights, roof hatches, destination sign exterior, etc. Brakes: includes all air and hydraulic brake components. Interior Bus - Passenger Compartment: includes seats, flooring, bus drivers compartment, doors, wheel chair lift and seating components, lighting, wiring, ballasts, cameras, video devices, destination sign interior, and other interior devices.

Table 8. Breakdown of fire origin based on location of the fire on the bus.

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An analysis by cause of the 120 fires within the study provides 9 specific areas of causes that provides a very clear trend. The two most frequently occurring categories are non-maintenance random failures and non-maintenance manufacture design. The combination of non-maintenance causes represents 59% of all fires over the period of the last 5 years. Random failures are parts or components that internally fail or are not required to be maintained during preventive maintenance activities. Design issues are those fires that include improper routing of cables or hoses, or inaccessible components which require service or inspection activities. This is significant to offer the opinion that the transit systems were responsible for only 28% of the fires occurring on their buses. In true numbers this represents 36 bus fires within the study period or an average of 7.2 fires per year associated with the failure of the transit systems employee responsibilities overseeing approximately 11,000 buses statewide. Where the transit system was held responsible, 17 times (14%) it was determined the lack of skill of the mechanic was the probable cause, 8 times (6.6%) failure to detect, 4 times (3.38%) lack of training, and 1 time (0.9%) lack of skill of the bus operator. Supervision was held responsible in 6 of the 36 bus fire events (5%).

Table 9.

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Events by Source Evaluation of fire events by source of the fire provides identification of the individual areas which will be suspect in future fires. Those areas typically either contain a source of fuel or a source of ignition. Fuel sources include diesel or gasoline, hydraulic oil, coolant, and contaminated air. Ignition sources typically include the engine, turbo-charger, exhaust, electrical wiring or connections, brakes and tires. Table 13 provides a breakdown of both ignition and fuel sources. The highest number of fires has been a result of compromised ignition sources, specifically electrical in nature, representing 50% of all bus fires. This number includes both maintenance related and nonmaintenance components. The most common issue of an electrically ignited fire is a ground short condition. These mostly occur when coated, hot wires chafe against a metal surface and wear to the wire, creating a short to ground. The wire is supercharged and overheated, sometimes arcing like a welder. The heat and arcing can either start the wiring on fire or surrounding materials or cut through high pressure lines, supplying an atomized fuel resulting in a substantial fire event. High pressure lines are the second leading source of fires. High pressure allows liquids to atomize into a vapor and flash ignite much more easily than the substance as a liquid. Any of the pressurized lines can be a substantial source of fuel for a fire. Fuel lines and hydraulic oil lines are manufactured to withstand years of service in the engine compartment, but when failures occur, through chafing, leaking fittings, or catastrophic failures, the results can be a fire that has a fuel supply sufficient to create a very hot, fast burning fire that can completely destroy the bus. Several PTSB investigated events involved buses burned from the engine to the drivers compartment, with only a skeleton frame in between. These fires spread quickly throughout the passenger compartment due to the combustion of construction materials and flow of super heated smoke through the ventilation system of the bus. Additional fire sources can be overheated brakes, defective wheel bearings, and under-inflated tires. Tires pose a serious threat to a fire when driven on in an under inflated condition. This can occur at any tire position, but mostly occurs at the dual wheels where one tire is properly inflated and the other in a low air condition or flat and rubs the road surface or the other tire until heat is generated to the point of combustion. Once combustion occurs, the tire is able to supply sufficient fuel to the fire to support a significant fire event. Tire fires are marked by heavy, black, toxic smoke and are difficult to extinguish. Smaller on-board fire extinguishers are not capable of snuffing out a tire fire which sometimes allows the fire to spread to the passenger compartment of the bus prior to the arrival of professional fire fighters. Some auto extinguishing systems offer the option to install heat and fire detection along with extinguishing equipment (nozzles, etc) to the wheel well areas. These are most commonly used on over the road coaches. Engine compartment fire extinguishing equipment is commonly used on transit equipment starting back in the 1990's. The addition of alternative fueled buses with hotter running engines and various other types of alternative fuels used as propellant (CNG, methanol, propane, etc), have required the additional use of suppression devices in the engine compartment. The PTSB investigations conducted on buses that have suppression systems on-board have revealed substantially less fire damage to the bus and less passenger compartment intrusion by fire on those vehicles. This is notable, as the less heat, smoke and fire that enters the passenger compartment, the less chance of passenger injuries.

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Table 10

Table 11 condenses the sources of fires within the study period reflected in Table 10, and shows the largest percentage of fires (51%) are attributed to non-maintenance sources. Electrical sources represent 22%, and high pressure line sources represent 16 %. Table 11

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Table 12. Fires by age of bus.

Fires by Age Buses distributed throughout NYS which are purchased through a mix of Federal, State and local funds, are scheduled to be replaced on a 12 year life cycle. Some systems have continued to operate their buses for as many as 20 years. This table exhibits a trend for buses involved in fires occurring about the age of 6-7 years old. Approximately 28% of the total number of fires occur around 6 years of age. This trend may be attributed to failures that occur after engine rehab takes place, usually around 5-6 years, and both electrical and high pressure lines and connections have been disturbed, replaced and/or retrofitted.

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Table 13

Manufacturer of the Buses Involved in Fires Table 13 identifies the manufacturer of the buses involved in each fire from 2002 - 2006. The highest number of involvements are Orion buses accounting for 61 of the total 120 events. This represents 50% of the total number of fires. The second most represented is RTS and MCI, both with 8 (6.6%) involvements. The lowest (1%) are tied with 11 different manufacturers; Nabi, Nova, Prevost, Neoplan, Navistar, AI, Ford, Flxible, Cheverolet, Gillig, and Dodge. The Orion manufactured buses are the most represented number of buses in the statewide fleet (approximately 40%), as such represent the highest number of involvements. Table 14 is a breakout of this table, selected to review the fire sources of Orion buses since it represents a significant total number of fire events.

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Table 14

A review of Table 14 exhibits most fires involving Orion buses involve an electrical source, either considered maintained by transit staff or a non-maintenance item in 53% (31 of 58 events) of the time. Approximately 27% of the time, the source was a non-maintenance electrical item. The total number of non-maintenance or unknown sources was 55% (32 of 58 events) involving Orion buses. Table 15, Exhibits the 5 most common bus manufacturers in New York State as a percentage of the national bus fleet for the year 2006. Orion (36%) and Nova (20%) make up 55% of the total NYS fleet. Table 15

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Table 16

Table 16, represents the breakdown of the four most common manufacturers by the NYS bus companies (CDTA, NFTA, MTA LIB and MTA NYCT) experiencing 85% of the fires occurring in the study period, 2002-2006. Orion, representing 38% of the group (most common) has been involved in 50.8% of the fires. Nova, representing 28% of the fleet (second most common) has been involved in 5.8% of the fires. Orion and Nova together represent 66% of the buses in service at these four authorities.

Table 17, shows the NYS percentage of miles of revenue service for the 5 most common manufacturers in the State fleet. Again, Orion (34%) and Nova (21%) represent the most revenue miles for services provided at these four selected authorities (CDTA, NFTA, LIB, and NYCT). Page 15

Table 18

Table18, represents the 5 most common manufacturers revenue fleet miles by bus companies with the most number of bus fires (CDTA, NFTA, MTA LIB, and MTA NYCT)

Note: There were d ifferent da ta sets used to p rovid e inform ation for this report. Some o f the charts reflect data that was extrapolated from national data sets based on information that was available at the writing of the report. Every reaso nable effort was made to provide valid information. The recommendations are based on sound p rinciples of safety management and are supported by the industry peer committee notwithstanding the information gleaned from the data set

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Summary Findings
The review of the 120 bus fires investigated by PTSB staff and which occurred between 2002 and 2006, have identified several of the most commonly known causes of bus fires. Two causes in particular that have also plague bus fleets across the country and have the highest rate of occurrences in NYS are those fires related to electrical and high pressure fluid line failures. In NYS, during the study period, 74% of all reported fires (89 out of 120 total) involved these two areas. Some occurrences have involved both, where an arcing electrical short has cut into a high pressure line, resulting in a continuous ignition source (until the breaker cuts the power supply) and a substantial atomized vapor fuel source. Modern day bus engine compartments running in service under normal conditions are also experiencing increasing engine temperatures. Over the past 10 years some engine components have common operating temperatures 100 degrees hotter than in past years. This has, in some circumstances, increased operating temperatures greater than the flash points of common fluids necessary to run the engine. Flash points of vaporized fluids are lower than auto ignition temperatures. Obviously, a spark is hotter than any operating temperature and can lead to ignition of any volatile leaking fluid. A static spark is capable of igniting flammable atmosphere if the arc can transfer enough energy to heat a sufficient volume of the gas to sustain combustion after the arc is extinguished. A table of comparison temperatures is provided in Appendix D. Once a fire ignites, the temperatures can reach in excess of 1500 degrees and can consume almost all of the vehicle, including melting the metal framing and other support components. This can result in a total loss of the bus, which may have been over $500,000 when new. NYS Transit Industry Response An example of the NYS transit industry responding to an issue can be seen it the events following several fan motor fires which resulted in significant property damage. The issue was an O ring inside a hydraulically driven fan motor, which was a common source of hydraulic oil leaks. This unit was the power drive for the cooling fan and was located above the engine. It was powered by high pressure hydraulic fluid and was prone to leaking after being serviced. Oil would escape from the O ring seal and contact the hot surface of the engines turbo charger. Since the turbo ran hotter than the flash point of the hydraulic fluid, a fire was a common result. A request to the manufacture to re-design the part was not successful. In response, the maintenance department of a New York based transit company re-engineered the part to eliminate the torque on the O ring, and was credited with eliminating the occurrence of these fires due to the faulty application. A PTSB Safety Advisory was issued to inform all systems statewide. The photos below provide a before and after view. Other types of fluid related fires have been tied to failures of hoses, fittings and couplings. This can be a non-maintenance catastrophic failure of the line, fitting or coupling or it can be a failure based on a human error such as a mechanic using the wrong replacement item, an improperly rebuilt connection or miss-routing the line through an area that results in chafing and eventual failure.

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Before and after views of the redesigned hydraulic fan motor. The new assembly eliminated the need for maintainers to position the O ring and ende d the ra sh of fires.

Figures 1 and 2

Electrical Failures Electrical failures are common with all bus types. This includes a rise in the number of electrically related incidences with newer buses whose operational demands have increased the number of feet of wire snaked throughout the bus, the demand loads, and extra vigilance required by maintenance staff performing their monthly PMI services. This includes checking for chafing wires, proper wire and hose routing, adequate stabilization of cables and hoses using plastic P-clamps (instead of metal) or other technology, searching out leaks, and ensuring proper connections (double nuts to studs without cracking the ceramic insulator, positive terminal boots, secure firewall connections). This supports the use of commercially installed fire suppression systems directly from the original equipment manufacture. Several types and manufactures are available. They are generally installed in the engine compartment and sometimes the wheel well area. They deploy an extinguishing agent through nozzles located in strategic locations with automatic temperature or flame sensors and/or a manual dump valve switch controlled by the bus operator. They are effective in reducing the spread of engine fires and therefore repair costs, but more importantly gain vital time necessary for a full evacuation of passengers from the bus in a safe and orderly fashion. Since the widespread application of suppression systems began in the early 90's, systems are experiencing fires that result in less damage. The systems can be re-charged and put back in service multiple times. Mechanics performing PMIs must also be properly trained to recognize other issues such as turbo charger premature failures, wheel seals and bearing quality, brake component effectiveness and proper airing of the tires. These efforts must be in compliment to a proper pre-trip and post-trip inspection program by bus operators. Tire Fire Involvements Tire fire involvements, created by excessive heat from the rubbing rubber on the road surface or against the other dual tire can usually only be contained by professional fire fighters. The on-board extinguisher (usually a 5 lb CO2 type) can be used during the ignition stages only, and generally are ineffective to extinguish tire fires. Although suppression systems are available for the tire wheel well areas, they are not always effective for extinguishing a tire fire. A different concept used to reduce tire fires is the use of tire pressure monitoring systems. These systems are more commonly found in over the road coaches and allow a driver to monitor tire pressures from the drivers compartment. The driver is given a warning when tire temperatures reach a certain threshold indicating danger. This is still considered fairly new technology and is not in use in many transit fleets.

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Particulate Trap Filters The latest growing frequency of fires has been occurring in the area of the roof where the exhaust pipe exits the top of the bus. Modern design particulate trap filters (new technology) that burn excess carbon particulate, are located near the tail end section of the pipe. The temperatures are hot enough that the manufacture has installed heat shields or blankets to the pipes to avoid potential fires. If work is performed in the area, requiring a mechanic to remove and replace the shields but does so improperly, a fire can result. This has occurred enough times that one transit system has relocated the left roof marker light and its wiring harness out of the way of the excessive heat in an attempt to eliminate this fire potential.

Report Recommendations
The review of a five year history of bus fires from 2002-2006 has revealed that although most fires have been attributed to causes deemed either non-maintenance or random component failures, there is a great deal transit systems can continue to do to reduce bus fire events. Human failures still occur in areas such as : - improper repairs - neglect - lack of training - lack of supervisory oversight - failure to detect - lack of skill - bus operator, maintainer, or supervisor - improper policies and procedures In order to reduce bus fires, transit systems must be vigilant, using foresight, in determining when preignition conditions exist that can be corrected during the life expectancy of the bus. These conditions can exist from the very first day the vehicle is on the property to the last month of its life span, when deferred maintenance is very common. Specific Action by Responsibility: Statewide Industry (in cooperation with NYSDOT) PTSBFR08-1 - develop and task an industry based committee to provide feedback, support, information, and direction towards minimum procurement standards and recommendations for future bus purchases aimed at reducing bus fires - develop a database of information on fires statewide that includes causes of fires, tracking related parts (by model, serial number and manufacture), evaluation of suppression system effectiveness, and statewide recommendations to bus systems for improved performance Page 19

PTSBFR08-2

PTSBFR08-3

- develop interface with industry partners such as NYSDOT, PTSB, APTA, NFPA, bus manufacturers, suppression system manufacturers, component manufacturers, and others involved in the prevention of bus fires

All Bus Transportation Systems (under PTSB jurisdiction): Management PTSBFR08-5 - provide direction and oversight thru policies, procedures, and training to reduce the occurrence of bus fires throughout your system, incorporating at minimum, the following recommendations:

Maintenance PTSBFR08-6 - gain understanding which parts fail and why particular parts fail at an unexpectedly high rate - track part model and serial numbers, and manufacturer name of failed parts resulting in fires - eliminate as many fluid leaks as possible (fuel, hydraulic, coolant, oil, etc) - keep ignition points protected, covered, clean, and other debris away; engines clean of grease, oil, and other fuel sources for fires - constantly inspect for chafing wires and hoses, track previously failed areas, and increase vigilance in those areas - ensure proper training of mechanics and technicians to perform duties properly and keep staff informed of findings of fire causes -train technicians to properly diagnose a dangerous condition and effect a proper repair; properly identifying and repairing leaking high pressure lines and chafing electrical wiring, the two most common sources of fires - eliminate all areas of water intrusion - understand new technology, such as particulate trap regeneration systems that operate at very high temperatures and require special training to properly perform work on these components as well as updating PMI forms and procedures as needed - keep all fire and heat sensors clean and in proper operating condition

PTSBFR08-7

PTSBFR08-8 PTSBFR08-9

PTSBFR08-10

PTSBFR08-11

PTSBFR08-12

PTSBFR08-13 PTSBFR08-14

PTSBFR08-15

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PTSBFR08-16

- be vigilant to incorporate retrofit and recalls with proper corrective and preventive maintenance practices. - ensure buses that are overhauled or rehabilitated due to high mileage or hard service life are given quality control inspections in areas where electrical cables, high pressure lines and connections, junction boxes, and other retrofit components are installed - use of quality OEM or equal replacement parts is highly beneficial - use quality control inspectors or supervisors to ensure work performed on parts frequently related to fires are inspected during and at the completion of the task especially such areas as starters, generators/alternators, air conditioning units, wheel bearings, brakes, exhaust heat shields, turbo charger heat shields, battery cables, and other related components

PTSBFR08-17

PTSBFR08-18 PTSBFR08-19

Procurement/Rebuilds PTSBFR08-20 - establish procurement standards for requiring quality parts and vehicle components, along with fire resistant materials, and fire suppression systems - use non-metallic P-clamps and electrical wire retention and support devices - consider upgrades of capacity of fire extinguishers for onboard use by bus operators

PTSBFR08-21 PTSBFR08-22

Operations PTSBFR08-23 - ensure training of bus operators includes fire safety procedures and emphasizes the importance of passenger safety and immediate evacuation of the bus in a safe location, securement of the bus along with dispatch notification - ensure bus operator training and annual refresher include early detection and symptoms of potential fires such as leaking fluids (engine and wheels), low air in tires (especially duals), changes in gauge readings on instrument panel, loss of drive power, smell of overheating conditions, poor brake performance, lack of turbo power, etc - ensure dispatchers and road supervisors are competently trained to provide bus operators proper direction in the event of a smoke condition - commonly in the areas of the engine, tires, brakes, and dashboard; also how to access power cut off switches

PTSBFR08-24

PTSBFR08-25

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Safety PTSBFR08-26 - conduct safety oversight thru competent investigations for causes of fire incidents, disseminating the information, and improving the policies and procedures based on what was learned - conduct ongoing quality control inspections to ensure the safety of buses in service - ensure bus operators are conducting proper pre/post trip inspections as they provide critical aid for the mechanics in order to allow them to perform their jobs correctly - provide fire safety information to system employees thru safety meetings, bulletins, refreshers, and ongoing outreach efforts

PTSBFR08-27

PTSBFR08-28

PTSBFR08-29

Further study should be conducted beyond the availability of information found within the 120 investigative reports of the PTSB throughout this 5 year period of history. As more high tech, integrated technology is adopted into the day to day operation of a transit system, efficiency to operate and ability to detect inefficiency of safe operation of the vehicle must grow continuously. Some new technologies have been beneficial to reducing fires. LED lights burn significantly cooler than incandescent bulbs which can hold a temperature of over 700 degrees at the glass bulb. Also, best practices exist, for example, where one transit system replaces all hoses throughout the engine compartment whenever an engine overhaul is completed. At a cost of $1300 to $1800 depending on model, the system has effectively eliminated hose failures relating to bus fires. Another system was experiencing brake caliper failures due to rusting and seizures, which eventually lead to overheating and fires. The system determined it was necessary to use only one brake pad supplier which provided a superior part that resisted the effects of expansion due to overheating. Brake fires were eliminated. The application of tire pressure monitors could also be used, although this most probably would be most effective for over-the-road coach systems. The transit industry has also begun to examine the use of hydraulic fluids with higher flash points. The Federal government has been experimenting with low and non-flammable fluids for many years in military and aeronautical applications. Using the knowledge others have developed in similar applications could save years of research. One system in NYS switched from standard hydraulic fluid to motor oil, which has a higher flash point and the company saw a reduction in fluid related bus fires. In closing, the potential for catastrophic events that include human loss as a result of a bus fire makes it essential for government, industry and manufacturing to work cooperatively to ensure the safety of all passengers, employees and the traveling public. The PTSB has remained vigilant, conducting investigations into causes and sources of bus fires for the past 24 years. Although the incidence of injury has been extremely low in New York, other locations in the US and throughout the world have experienced horrific losses due to bus fires, demanding our continual oversight of our systems here in New York State. The review of bus fires from 2002-2006 has revealed that although most fires have been attributed to causes deemed non-maintenance, random component failures, there is a great deal transit systems can continue to do in support of reducing bus fire events. Page 22

Appendices PTSB Bus Fire Scope of Study ........................................................................................................A Previous Activities Regarding Bus Fires in NY ...............................................................................B Common Temperatures Associated with Buses ...............................................................................C PTSB Safety Advisory :MCI Bus Fires, Nov 9, 2005 .....................................................................D PTSB Safety Advisory: TMC/RTS Fires, July 2003.........................................................................E PTSB Safety Advisory: Blue Bird Bus Fires ....................................................................................F Coach USA: Fire Bulletin ................................................................................................................G MTA-NYCT Maintenance Directive; Artic.Buses, Starter Cable Chafing Concern, 2007 ...................................................................................................................................H National Transit Database, Safety and Security Newsletter, Vol.3, Spring 2005 ..................................I FTA National Transit Statistics - Injuries from Fires, 1998-2007 ....................................................J USA Today, Article; Most Bus Fires Unrecorded, 2006................................................................K PTSB 31 Form, Bus Fire Investigation Data Forms, 2002 thru 2006...........(available upon request)

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PTSB Bus Fire Scope of Study

Appendix A

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Appendix B

Previous Activities Regarding Fires in NY

PTSB Safety Advisories
The PTSB will issue a Safety Advisory to affected parties whenever an accident cause is identified. Sharing the information may assist in preventing the occurrence of a similar event at another location. PTSB staff on several occasions have worked with the federal and other state governments, or specific bus manufactures to disseminate information on fire causes. Electrical Shorting On July 15, 2003 (Appendix C), the PTSB staff issued a safety advisory alerting all transit bus operators under PTSB jurisdiction of an electrical shorting condition found on TMC/RTS buses that lead to two different fires involving 1993 and 1994 buses. The specific issue involved a P clamp connected to wiring bracket which became fatigued over time and allowed a starter cable to chafe and ground to short. The issue of future fires was resolved by the addition of an intermediate bracket which voided the chafing of the starter cable to the engine cradle. No other similar fires were reported. Motor Coach Fires On July 8, 2005 (Appendix D), the PTSB staff issued an advisory after investigating two MCI, Model DL-3, 45 foot, motor coach fires. Each fire was similar in nature and involved the shorting of the light ballast in the overhead lighting in the passenger section of the bus. This was particularly dangerous in that the bus had only one door at the front of the bus for quick exit (buses also had emergency windows, wheelchair door and roof hatches). However, the ballast is located in the front of the bus just behind the drivers compartment and the area where the fire extinguisher was stored. Buses were found to be experiencing water intrusion thru various areas and this resulted in electrical corrosion of the ballast components. As a precaution, all ballast controlled lights in all effected MCI DL-3 buses were disconnected and through an agreement with the MCI, all buses were rewired and water intrusion issues were eliminated. The National Highway Traffic Safety Administration (NHTSA) Office of Defects Investigations was also notified and informed of the issue. Chafing Wires In the past, the PTSB staff has worked with a jurisdictional bus company where a bus fire has occurred to oversee that policy directives be issued internally to aid in the dissemination of information and proper modification of maintenance techniques that may have been related to a human causal or failure event. An example of a maintenance directive, filed on March 9, 2007, by the MTA-NYCT states the specific concern of chaffing wires which ground to a short and caused a fire. The directive, sent to all appropriate parties within the system, provides the necessary corrective action, along with documentation including photos of the improper wiring and new wiring configurations. Page 25

Improper Direction From a Dispatcher The PTSB staff also ensures that operations personnel are properly trained and providing sound advice to bus operators when a situation occurs. Such as the situation with a Coach USA bus operator (Appendix D) who was given improper direction from a dispatcher to continue on his route after he called into the dispatcher complaining about a smoke condition. This resulted in a significant fire event with no injuries. The company responded appropriately by issuing a directive to all affiliated systems in NYS and countrywide, retraining the dispatcher, and stressing the importance of stopping the bus immediately (in a safe location) anytime there is a fire threat.

Bus Accident Investigation Training For Identifying Safety Hazards (BAITFISH) The PTSB Bus Accident Investigation Training For Identifying Safety Hazards (BAITFISH) program includes a one day facility maintenance training program (BAITFISH 4). This is taught program experts to identify the specific areas of concern when NYSDOT inspects a bus for certification purposes. The class also includes open discussion of industry standards and best practices to avoid maintenance situations that can lead to fires and road side breakdowns.

BUS FIRE DEMONSTRATION CONFERENCE

In 2003, the staff coordinated a conference with the New York Statewide Traffic Accident Reconstruction Society, centering around bus and rail accident investigation technologies. The last day of practical testing ended with a staged enactment of a bus fire. The 1996 GMC RTS forty foot transit bus was filmed as it was consumed by fire in less than four minutes.

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The amount of materials inside the bus, such as seats, flooring, etc that give off highly toxic fumes as they combust create an un-survivable environment.

During the fire demonstration it was clearly established that the interior of the bus was unsurvivable after one minute of interior exposure to the fire. The first photo shows heavy smoke after two minutes, the second and third photos show the quick progression to total involvement in less than 6 minutes.

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Appendix C

Common Temperatures Associated With Buses

Auto Ignition Temperatures of Fluids Commonly Used on Buses Diesel Fuel Engine Oil Power Steering Fluid Transmission Fluid Hub/Gear Lubrication Oil Coolant (50/50 mix) Tires (smoldering) 445 degrees 450 degrees 420 degrees 420 degrees 430 degrees 900 degrees 450-500 degrees

Common Surface Temperatures of Engine Components on Buses in Service Turbo Charger Engine Exhaust Exhaust Manifold Disc Brake Rotor Diesel Particulate Trap Filter 610 degrees 585 degrees 390 degrees 420 degrees 600 degrees (min.) Regen up to 1500 degrees

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