Bus fire inquiry finds problems

[TexasStooge]

Exclusive: Worn parts, oxygen mishandling fueled fatal blaze

By MICHAEL GRABELL / The Dallas Morning News

The wheel bearings that started the bus fire were so worn that they had fused together. The oxygen bottles that popped, accelerating the flames, were stored haphazardly. And a mysterious liquid was seen puddling under the bus during an earlier stop.

These are some of the findings of a Sheriff's Department investigation that provides the first inside look at how poor maintenance and negligent oxygen storage probably combined to create the Sept. 23 bus fire in Wilmer that killed 23 nursing home patients fleeing Hurricane Rita.

The complete case file, obtained by The Dallas Morning News, reveals that there were too many oxygen tanks in the passenger cabin, that two tanks ruptured and one melted in the fire, that others were left unsecured in the cargo hold and that the bearings had rusted, fused and broken off over time, probably causing the fire.

The Dallas County sheriff's investigation into the deadliest U.S. transportation accident since a 2001 plane crash now has been forwarded to the National Transportation Safety Board, which will make a final ruling in six months to a year.

Kenneth Mead, inspector general for the U.S. Department of Transportation until last month, said the fire could have a significant impact on the busing industry.

"We know it was carrying the elderly," he said. "We know it was carrying oxygen. We know the oxygen exploded. And I think there were a number of other issues concerning compliance with the applicable rules.

"All of those contain a lot of potential for lessons learned."

The Dallas County sheriff's case includes witness statements, investigators' conclusions and more than 1,300 crime scene photos.

An attorney for the bus operator, Global Limo, could not be reached for comment. Sunrise Senior Living, which owns the nursing home where the patients lived, declined to comment because of pending litigation.

Oxygen bottles

One of the worst transportation accidents in recent history – the 1996 crash of ValuJet Flight 592 in the Florida Everglades – also involved the storage of oxygen. But changes resulting from the crash applied only to aviation.

Within hours of the bus fire, the U.S. Department of Transportation issued guidelines to the industry on how to safely transport medical oxygen.

But the guidelines were only recommendations. There are still no federal regulations about carrying oxygen on a bus, and drivers aren't required to be trained on how to store it.

The new guidelines stated that oxygen cylinders should be secure in an upright position to prevent movement when the bus is in motion. The number of canisters in the passenger compartment should be limited to one per patient.

While only two patients on the Global bus needed oxygen, at least five containers were in the passenger compartment as the trip neared its end, according to the sheriff's investigation. When deputies found the canisters after the fire, two were ruptured, one was melted and two were whole.

"The oxygen in these bottles fueled and intensified the fire causing it to spread very quickly," the report said.

Crime scene photos show some oxygen containers were stored haphazardly. In one photo, two containers are stuffed among luggage and wheelchairs in the cargo compartment. One is tilted and resting on a wheelchair.

"Obviously they're not secure," said Capt. Mike Buehler, who was not part of the investigation but is president of the Dallas Fire Fighters Association. "If the oxygen is released from those bottles, it is going to feed the fire and cause it to intensify."

Brighton Gardens of Bellaire caregivers told the NTSB that they started the trip with 17 oxygen bottles. Two were used by patients on the bus. Fifteen were stored underneath: nine in a wooden crate and six on a metal cart.

Patients already were running out of oxygen after a four-hour drive from Bellaire to Humble, which normally takes about 30 minutes. The caregivers stopped on the side of the road and switched containers.

In Huntsville, they stopped to refuel and decided to bring up more oxygen bottles to avoid stopping again to replace empty ones.

"I put all four of them on the floor, and I took the blue cooler and wedged it so they wouldn't move," nursing assistant Sheila White told the NTSB. "And there were two empty ones that were standing sitting behind an empty seat, and I took a cooler – a plastic cooler – and I shoved it so they wouldn't [be] clacking together."

Neither the sheriff's investigation nor the NTSB interviews indicate how the oxygen bottles ruptured. A Brighton Gardens caregiver, Ayelech Tayework, told a sheriff's deputy that she shut off the bottles used by patients before flames reached the cabin.

One of the patients on oxygen, Gloria Putney, made it off the bus before two of the five containers popped, incinerating the bus.

Worn bearings

Ruptured oxygen bottles fueled the fire, but crime scene photos show that the poor condition of the right rear wheel bearings may have led to the fire.

In the days after the fire, investigators stripped the bus of all its parts and tagged them for metallurgical tests. Some of the damage was evident.

The circular cage that holds the bearings is broken off and dangles like a necklace on the spindle. A section of bearings is missing, the photos show. And several others – which are usually silver and separate – have become rusted and fused.

"Those bearings welded themselves together they got so damn hot," said Andy Priest, a private accident investigator who reviewed the photographs for The News.

The condition of the bearings supports initial indications that poor maintenance was to blame for the fire.

Based on the thick layer of rust near the bearings, the heat appeared to have built up over a period of time, said Mr. Priest, who has been deconstructing crashes for police agencies, law firms and insurance companies for 35 years.

Such damage would have allowed the rotor to wobble and grind against the brake caliper, which holds the brake pads that compress to slow down the bus, he said. A picture of the caliper shows a clean break on one side.

If the other side also broke, "the wheel would have zinged off," Mr. Priest said. "The only thing that kept the wheel on was the caliper."

One of the unanswered questions in the bus fire investigation is what effect an earlier flat tire had on the condition of the wheel.

The right rear tire popped about 3:45 a.m. in the city of Rice, north of Corsicana. It was in an Interstate 45 construction zone, and the driver had to stop in a lane, aggravating the traffic backup that stretched from the Gulf Coast to Dallas.

K&S Tire Towing & Recovery, which helped change the tire, has said it didn't notice any obvious malfunctions.

But a Rice police report and witness statements reveal that people who gathered to help noticed liquid pooling near the right rear axle.

"I mentioned it to the others who were standing around," Marx Madison of the Texas Department of Transportation wrote in his statement.

The police report, written by Chief James McDuffie, says the K&S mechanic also noticed the liquid and reported it to the driver. K&S officials did not return calls.

Chief McDuffie told The News that the puddle was about a foot long and 6 inches wide. He said he didn't know what the liquid was but heard someone say it was air-conditioning condensation.

The Texas Department of Public Safety said a trooper returned to the site of the tire change and found it to be "oil that had dripped off the engine." But it was not enough of a concern for the trooper to take a sample for analysis.

Mr. Priest, the accident investigator, said the liquid could have been a number of things signifying a number of different problems.

"You could have had a cooling system problem, or if you had transmission fluid, your transmission would eventually quit working, or if it was a large amount of motor oil, your engine would seize up," he said. "If we had engine oil going on the brake, just hypothetically, engine oil will catch fire with heat."

Chief McDuffie said he and others checked the ground after the bus left and didn't notice any more liquid.

"It didn't appear to be a concern to the folks that were working on the bus," he said. "And of course at this point, you're looking at all the traffic."

[TexasStooge]

Exclusive: Driver's violations blamed in bus fire

Documents say deaths of 23 elderly evacuees preventable

By MICHAEL GRABELL / The Dallas Morning News

The deaths of 23 elderly Hurricane Rita evacuees in a horrific bus fire could have been prevented had the driver inspected the vehicle before leaving and known enough English to tell passengers where the emergency exits were, according to documents used to build a criminal case against him.

Those documents also assert that the driver, Juan Robles Gutierrez, admitted to investigators that he tried to avoid police detection by switching the bus's license plates.

"The combination of all of these factors proved to be lethal," Dallas County sheriff's deputies wrote. "The driver's actions, had he been in compliance with the laws of this state and the [Federal Motor Carrier Safety Administration], could have prevented the loss of 23 lives."

The documents, which include affidavits by investigators and passengers, shed light on why the sheriff's office decided to file a criminally negligent homicide case against Mr. Robles last fall in connection with the Sept. 23 bus fire outside Dallas – the deadliest U.S. transportation accident since a 2001 plane crash. Mr. Robles eventually was cleared by a Dallas County grand jury.

The case stirred a debate over whether Mr. Robles was an illegal immigrant who flouted U.S. laws or the hard-working victim of a boss who did.

Rodolfo Robles Gutierrez said his brother wasn't ready to be interviewed and shouldn't be blamed for the fire.

"He was not a mechanic," he said. "If he had ran away, then it would be negligence. That never happened. He always tried to cooperate and help."

Juan Robles Gutierrez's boss, Jim Maples, faces federal charges of falsifying driver logbooks and failing to maintain his buses. His attorney could not be reached for comment.

Mr. Robles has been ordered to stay in Houston to cooperate with the trial. He has yet to speak publicly about what happened during the 15-hour drive from the Houston area.

His 200-word statement to investigators provides the first look into his version of the events.

According to the statement, translated by a state trooper on the day of the accident, Mr. Robles was driving the bus in the left lane of Interstate 45 when he saw a white vehicle pull up beside him. The car then pulled in front of the bus and slowed down.

"Another vehicle informed me that there was fire coming out of the bus," he said in a separate statement written in Spanish.

Mr. Robles braked. He said he looked in his right-side mirror and saw flames climbing from the rear tire that had been changed two hours earlier, and he immediately pulled over.

He exited the bus and tried to smother the flames with his shirt, dirt, dry grass and water, he said.

He said he got back on the bus and tried to grab the fire extinguisher but couldn't. A nursing assistant told National Transportation Safety Board investigators that an elderly patient had her foot on it and wouldn't budge.

"It remained in its cradle unlatched until I pulled it off of the bus a day later," Sheriff's Department Sgt. Kevin Feinglas wrote.

Mr. Robles said he helped three passengers off the bus and continued to rescue people even after police arrived. He said he opened the first emergency window exit on the driver side and managed to get a second exit unlatched.

After helping the third passenger, he heard explosions and ran several hundred feet to the Mars Road underpass.

The sheriff's report said investigators couldn't verify his account of rescuing anyone. But nursing home caregivers have told the NTSB that they saw Mr. Robles help.

"A lot of people have called to thank my brother for his cooperation, the elderly themselves," Rodolfo Robles said.

The first time any deputy recalled seeing Juan Robles Gutierrez at the dark, chaotic scene was on the highway shoulder after the explosions.

"In the confusion, I came across the bus driver, who was wandering around the scene disoriented and with soot on his mouth and nose," Deputy Edward Wilson said in his statement. "I led him to nurses and asked him for his license. He gave me what appeared to be a Mexican DL."

The sheriff's report said Mr. Robles was negligent for not having a valid Texas driver's license. State law allows people to drive on a Mexican license for 30 days. Mr. Robles had been in the U.S. for seven months.

That prevented state officials from assessing his driving skills because Mr. Robles would have had to pass a written exam and road test to get a Texas license, the report said.

The report also faulted Mr. Robles for driving 15 hours nonstop and for not speaking English. Federal regulations say bus drivers must be able to read road signs, fill out their logbook, talk to police and converse with the public.

Mr. Robles was only able to communicate with the lead caretaker on the bus, Bonnie Estes, who spoke Spanish but was not fluent, nursing home staff told the NTSB.

"The driver could not speak English, only broken English at best," wrote Sgt. Feinglas, who prepared the sheriff's report. "He was unable to communicate with passengers regarding emergency exits prior to the trip, and he could not give them adequate warning that there were problems when the bus caught fire."

At the time of the fire, the bus, operated by Global Limo of South Texas, wasn't registered. It had a temporary paper tag that had been expired for weeks. Mr. Robles said he removed the tag and replaced it with the license plate from another Global bus "to avoid being stopped by the police," the report said.

It's unclear why Global didn't use the bus that the valid plate came from, but the one that caught fire was newer and had many luxuries older models do not.

Mr. Robles has been named as a defendant in at least a half-dozen lawsuits tied to the bus fire.

Vanesa Salinas of Al Día contributed to this report.

[TexasStooge]

Bus company seemed erratic with repairs

Vehicle in fatal fire repaired constantly at first; then fixes put off

By MICHAEL GRABELL / The Dallas Morning News

A loose mirror in the bus's bathroom was fixed. Burned-out turn signals were replaced. And the air conditioning was repaired over and over to get it to blow from the driver's-side vents.

But Global Limo never filled out required daily inspection sheets on the bus and didn't notice that its wheel bearings had worn so much that they would melt together from friction, probably causing a blaze that killed 23 elderly Hurricane Rita evacuees in September.

Global's maintenance files on the bus, obtained by The Dallas Morning News, provide new insight into the bus fire, which now involves myriad lawsuits, a federal criminal probe, a revamping of state evacuation plans and a transportation safety investigation of what caused the accident.

"It sounds like they were doing the things that were just minimally necessary to get by and to keep their customers superficially happy," said Larry Wilson, an attorney for the families of three victims.

The documents present a prickly path for safety investigators trying to determine what caused the fire and for federal prosecutors trying to prove that the company willfully overlooked maintenance.

There is no smoking gun and no mention of any repairs to the right rear axle, where the fire is believed to have started.

Global appeared responsive at times, bringing the bus in for service eight times in the first month of operation. But it seemed careless at other times, occasionally turning down a mechanic's recommended repairs because of time constraints.

"They did what they had to do and nothing more," said Andy Priest, a forensic mechanical expert, who reviewed the file for The News. "I would have had someone go through that baby from top to bottom. I think you owe that to your passengers."

At one point, Global brought the bus to a Motor Coach Industries repair shop in Dallas because its front bounced when it went more than 50 mph. The mechanic found that the bolts that connect the front axle to the body of the bus were worn, the front rotors were bad and the bus needed alignment.

But Global decided not to have the repairs made, according to the invoice. And there are no records showing that the company ever fixed the problem.

"This is not good," said Mr. Priest, who has investigated accidents for police departments, law firms and insurance companies for 35 years. "It's maintenance that needs to be taken care of."

The News also reviewed 55 of the bus's daily inspection reports, which include only a date, bus number, signature and two boxes for whether defects were found. The forms are on the back of every logbook in English and Spanish.

Although Global drivers filled out the logbooks, not once did they check a box or write any notes about doing an inspection.

Juan Robles Gutierrez, the driver when the bus caught fire, didn't fill out any of his 104 inspection reports, all contained in a folder titled "Robles, Juan ­ Log Sheets."

Mr. Priest said it's not uncommon for bus and truck drivers to pay attention to logbooks but not inspection reports.

"That's not going to be something anybody's going to ask for," he said. "Unless a police officer stops a bus and they find there are umpteen jillion violations, it's not going to come into play."

The inspection sheets obtained by The News only went up to Aug. 15. It's unclear whether federal investigators seized the more recent records or whether Global didn't create documents for the month before the fire, when it was primarily involved in hurricane evacuations. The federal indictment on a charge of failing to complete inspection records also doesn't cite records for the bus's last month.

The maintenance records support the account of a Global driver, who told The News that when he picked up the bus in Toronto in late May, he had trouble with the ignition, the door wouldn't open and close properly, and the air conditioning didn't work.

The battery died before he and another driver could get the bus to Texas, and they had to pull into a truck stop outside Little Rock, Ark., for a jump-start.

Then they brought the bus to the manufacturer's service facility in Dallas, where mechanics found that the passenger door had been rigged to work, and they replaced the sensor. They also found severe Freon leaks, dirt and rust on the AC.

The file also contains information about parts of the bus that might bear on the early-morning evacuation Sept. 23 that reached a dark, rural stretch of Interstate 45 outside Wilmer.

On June 14, Motor Coach Industries mechanics changed the bulbs on inside lights but said a module on the electrical system needed to be replaced. They also said window latches were worn. But the service center was out of stock on the module and latches.

Meanwhile, an inspection form shows that emergency doors, lights and push-out windows were last checked on June 27.

"It might have passed a cursory look," Mr. Priest said. "The physical component may be there, but it's worn out."

Despite bringing it in eight times in the first month for repairs and inspections, Global fixed the bus only twice from July through September, the maintenance file shows.

In early August, Global brought it to Valley Volvo Truck Center in Pharr, the South Texas town where Global has its office and bus lot. Mechanics repaired a leaking radiator, changed the transmission fluid, replaced the fuel filter and installed an air compressor gasket that had blown, the invoice shows.

And on Sept. 21 – hours before Mr. Robles left Pharr to pick up the nursing home patients in the Houston area – two new tires were mounted on the front of the bus, according to a receipt. There are few details about that repair, and the name of the company is illegible.

But Mr. Priest said it might indicate that a flat tire on the bus two hours before the fire wasn't caused by worn treads but by something else. Though only the front tires were replaced, the salesman would have looked at all the tires.

The last time the right rear tire was changed previously was May 31, according to maintenance records.

Other than during that tire change, it doesn't appear from the file that anyone looked at the lubrication of the bearings.Dallas County sheriff's crime scene photos show that the bearings on the right rear axle had rusted and fused together, that some had broken off completely and that a circular cage that holds the bearings had snapped and was dangling on the spindle like a necklace.

"Shame on them for not maintaining the bus," said Ray Putney, whose mother survived the fire but suffered severe smoke inhalation. "My mom's in a hospice now. We're not going to have her much longer."