BUS SAFETY INVESTIGATION REPORT

FIRE INVOLVING STA BUS MO4878

HILLSDALE, NSW
29 JULY 2011




BUS SAFETY INVESTIGATION REPORT
FIRE INVOLVING STA BUS MO4878

HILLSDALE NSW
29 J ULY 2011



















Released under the provisions of
Section 45C (2) of the Transport Administration Act 1988 and
Section 46BA (2) of the Passenger Transport Act 1990

Investigation Reference 04520




Published by: The Office of Transport Safety Investigations
Postal address: PO Box A2616, Sydney South, NSW 1235
Office location: Level 17, 201 Elizabeth Street, Sydney NSW 2000
Telephone: 02 9322 9200
Accident and incident notification: 1800 677 766
Facsimile: 02 9322 9299
E-mail: [email protected]
Internet: www.otsi.nsw.gov.au


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Investigations has been obtained.




THE OFFICE OF TRANSPORT SAFETY INVESTIGATIONS

The Office of Transport Safety Investigations (OTSI) is an independent NSW agency whose
purpose is to improve transport safety through the investigation of accidents and incidents in
the rail, bus and ferry industries. OTSI investigations are independent of regulatory,
operator or other external entities.

Established on 1 J anuary 2004 by the Transport Administration Act 1988, and confirmed by
amending legislation as an independent statutory office on 1 J uly 2005, OTSI is responsible
for determining the causes and contributing factors of accidents and to make
recommendations for the implementation of remedial safety action to prevent recurrence.
Importantly, however, OTSI does not confine itself to the consideration of just those matters
that caused or contributed to a particular accident; it also seeks to identify any transport
safety matters which, if left unaddressed, might contribute to other accidents.

OTSIs investigations are conducted under powers conferred by the Rail Safety Act 2008
and the Passenger Transport Act 1990. OTSI investigators normally seek to obtain
information cooperatively when conducting an accident investigation. However, where it is
necessary to do so, OTSI investigators may exercise statutory powers to interview persons,
enter premises and examine and retain physical and documentary evidence.

It is not within OTSIs jurisdiction, nor an object of its investigations, to apportion blame or
determine liability. At all times, OTSIs investigation reports strive to reflect a J ust Culture
approach to the investigative process by balancing the presentation of potentially
judgemental material in a manner that properly explains what happened, and why, in a fair
and unbiased manner.

Once OTSI has completed an investigation, its report is provided to the NSW Minister for
Transport for tabling in Parliament. The Minister is required to table the report in both
Houses of the NSW Parliament within seven days of receiving it. Following tabling, the
report is published on OTSIs website at www.otsi.nsw.gov.au.

OTSI cannot compel any party to implement its recommendations and its investigative
responsibilities do not extend to overseeing the implementation of recommendations it
makes in its investigation reports. However, OTSI takes a close interest in the extent to
which its recommendations have been accepted and acted upon. In addition, a mechanism
exists through which OTSI is provided with formal advice by the independent transport safety
regulator (ITSR) in relation to the status of actions taken by those parties to whom its
recommendations are directed.
OTSI Bus Safety Investigation
Fire Involving STA Bus MO4878, Hillsdale, 29 July 2011 i
TABLE OF CONTENTS

TABLE OF PHOTOGRAPHS AND TABLES ii

ACRONYMS AND ABBREVIATIONS ii
EXECUTIVE SUMMARY iii
PART 1 CIRCUMSTANCES OF THE INCIDENT 1
Incident Synopsis 1
The Bus 1
The Fire 4
Emergency Services Response 5
Damage 6
PART 2: ANALYSIS 8
Bus Inspections 8
Possible Causes 8
Electrical 9
CNG Fuel Leak 10
Oil leak 13
Coolant 14
Servicing and Maintenance 19
Development of the Fire 20
Mercedes-Benz 0C500 LE CNG Bus Fire in Australia 21
Other Safety Issues 22
Driver Training 22
Network Control 23
Dangers of CNG Fuel in Fire Incidents 23
Remedial Actions 24
PART 3 FINDINGS 26
PART 4 SUBMISSIONS AND ACKNOWLEDGEMENTS 27


OTSI Bus Safety Investigation
Fire Involving STA Bus MO4878, Hillsdale, 29 July 2011 ii
TABLE OF PHOTOGRAPHS AND TABLES
Photograph 1: Bus interior 1
Photograph 2: Electrical loom on tail shaft 10
Photograph 3: Ruptured CNG line-compared with an undamaged line 11
Photograph 4: Windscreen washer bottle 15
Photograph 5: Coolant return hose fitting misalignment 16
Photograph 6: Main coolant line reduction hose 16
Photograph 7: Split coolant return rubber connection 17
Photograph 8: Rear floor hatches 21

Table 1: Timed event summary 6







ACRONYMS AND ABBREVIATIONS

ADR ................... Australian Design Rule
CNG ................... Compressed Natural Gas
DIP ..................... Directly Involved Party
ITSR ................... Independent Transport Safety Regulator
OTSI ................... Office of Transport Safety Investigations
PTIPS ................. Public Transport Information and Priority System
RTA .................... Roads and Traffic Authority of NSW
1

STA .................... State Transit Authority


1
The operational elements of the Roads and Traffic Authority (RTA) were integrated with elements of both NSW
Maritime and NSW Transport and Infrastructure to form Roads and Maritime Services NSW, with effect 1 November
2011.
OTSI Bus Safety Investigation
Fire Involving STA Bus MO4878, Hillsdale, 29 July 2011 iii
EXECUTIVE SUMMARY
Shortly after 7.38pm on Friday 29 J uly 2011, a State Transit Authority (STA) bus
powered by compressed natural gas (CNG) caught fire when returning empty to the
Port Botany Depot. The driver, after being alerted to the fire by a motorist travelling
behind, stopped the bus and attempted to extinguish the fire with the only equipment
onboard, a small capacity portable extinguisher. His efforts were to no avail and the
bus was destroyed.
The investigation found that the most likely cause of the fire was coolant being
sprayed onto the engine from a split hose connection on the turbocharger coolant
return line to the compressor. The water content of the coolant evaporated on the hot
surface of the engine, allowing the residual ethylene glycol to crystallise and ignite.
As the fire intensified, it burnt through the rear floor hatch and ignited the seating and
other combustible interior materials.
Some 19 minutes after the fire was initially detected, a connection in the CNG line at
the engine succumbed to the intense temperature and resultant increase in
pressure, and vented a jet of flame. This secondary event occurred because the
driver did not shut off the CNG supply before leaving the bus.
The investigation found there were deficiencies in the training of drivers to handle a
vehicle fire. However, it was identified that Network Control personnel could assist in
emergencies involving gas powered buses by reminding drivers to shut off fuel
supplies, and by forewarning emergency services personnel of any known additional
hazards at the fire site.
The STA has implemented a range of appropriate remedial actions, the nature and
extent of which preclude the need for recommendations for further action by the
Authority. This action has included:
the replacement of the return coolant line and connecting hose fitting on all
their Mercedes Benz OC500 LE CNG model buses;
the calling of tenders for the retrofitting of fire suppression systems on all their
Mercedes Benz OC500 LE CNG model buses; and
OTSI Bus Safety Investigation
Fire Involving STA Bus MO4878, Hillsdale, 29 July 2011 iv
the provision of training and instructions to drivers and Network Control
personnel concerning actions to be taken when a bus experiences a fire or
thermal incident.
As a result of the number of bus and coach fires that have occurred in NSW since
the beginning of 2010, OTSI is undertaking a review of the results of the
investigations it has completed with a view to identifying and further examining any
systemic safety issues that become apparent.
OTSI Bus Safety Investigation
Fire Involving STA Bus MO4878, Hillsdale, 29 July 2011 1
PART 1 CIRCUMSTANCES OF THE INCIDENT
Incident Synopsis
1.1 At about 7.38pm
2
on Friday 29 J uly 2011, a State Transit Authority (STA) bus
(MO4878) caught fire on Beachamps Road at Hillsdale when returning empty
to the Port Botany STA Depot. Despite attempts by the driver and Fire and
Rescue NSW units, the bus was destroyed (see Photograph 1).

Photograph 1: Bus interior
The Bus
1.2 The bus was one of a fleet of 255 compressed natural gas (CNG) powered
Mercedes-Benz model OC500 LE buses owned and operated by the STA. It
was imported by Mercedes-Benz Australia in buggy format in J anuary 2007.
Completion of the body work and fit-out by Custom Coaches, Villawood,
NSW, commenced on 31 J uly 2007. MO4878 was first registered with the

2
All times in this report are Australian Eastern Standard Time (UTC+10 hours).
OTSI Bus Safety Investigation
Fire Involving STA Bus MO4878, Hillsdale, 29 July 2011 2
Roads and Traffic Authority (RTA) in December 2008 and last re-registered on
24 J anuary 2011, with Inspection Report AZ1129219 recording no defects.
1.3 Initially the RTA would not register these buses because they were
approximately 500kg overweight. However, modifications were made to the
buses to facilitate compliance with RTA requirements, although this resulted in
a delay of about 18 months before the buses could enter service. Included in
the work was some modification to the frames, rearrangement of passenger
distribution and the replacement of steel wheel rims with aluminium rims. The
255 CNG buses, as well as 200 diesel powered Mercedes-Benz model 0500
buses, were registered between 26 May 2008 and 6 J une 2011.
1.4 The body of the bus was constructed of welded stainless steel frames with
fibreglass side and roof panelling. The internal linings were predominantly of
composite plastic materials. Noise reduction was provided by polystyrene
infill between inner and outer panels on the sides and roof. The flooring
consisted of rot-resistant treated plywood with a covering of non-slip recycled
cork granules with a rubber binder. The seating consisted of plywood bases
and back supports mounted on stainless steel frames with foam filled seat
padding covered with cloth material. Although complying with clause 17 of
ADR 58 Requirements for Omnibuses Designed for Hire and Reward
Interior Fittings/Materials, the material used in the interior fit-out was
consumed rapidly once the fire breached the interior of the bus.
1.5 The bus had two doors, both of two leaf inward opening design, one at the
front opposite the drivers position and one on the nearside midway along the
length of the bus. There was provision for wheelchair passengers with flip up
seating in the front half of the bus. Emergency exit windows were located on
both sides of the bus above the wheelchair spaces.
1.6 The engine bay area, except for the floor-mounted inspection hatches, was
sheathed with stainless steel to protect the passenger area from heat from the
engine. The plywood floor service hatches at the rear of the passenger area
were not similarly sheathed with any such lining.
3


3
These hatches are in place to provide maintenance staff with access to bus driveline components. As the hatches are
regularly removed and refitted, the weight of a hatch is an OH&S consideration.
OTSI Bus Safety Investigation
Fire Involving STA Bus MO4878, Hillsdale, 29 July 2011 3
1.7 The bus was fitted with the Public Transport Information and Priority System
(PTIPS)
4
, closed circuit television (CCTV) and STA radio communications.
None of the OC500 LE CNG buses were fitted with a fire suppression system,
heat detectors, smoke detectors or alarms.
1.8 The bus had travelled more than 91,412km at the time of the fire.
5
It was
refuelled at the Botany Depot the previous day at 10.50pm and had travelled
97km before catching fire.
6

1.9 The bus was powered by a Mercedes-Benz OM 447 hLAG TYPE CNG-fuelled
six cylinder engine of 12 litres displacement. The engine had a lean burn
turbocharger with intercooler and a power rating of 185kW at 2000rpm. The
CNG fuel was stored in seven cylinders. The cylinder set is rated at 1055
litres of CNG when measured at a standard atmospheric pressure of
101.325kPa, but occupying 240m
3
when compressed to 200 bar (20mPa), the
operating pressure of the storage cylinders.
1.10 The CNG storage cylinders were installed by Custom Coaches in a fibreglass
pod on the roof towards the front of the bus with the gas supply line running
along the roof to the rear mounted engine. The supply line had two
emergency isolation (shut-off) valves: one on the offside of the roof-mounted
pod assembly which could be activated by a remote mounted emergency pull
handle located behind the drivers position and the other at the rear offside
corner of the bus which was accessible for operation only from outside the
bus. Both valves required a quarter turn between the open and closed
positions. The mounting of the CNG Pod and cylinder set was installed by
Custom Coaches. CNG installation and compliance was certified by RFD Pty
Ltd, which was a contractor to Mercedes Benz.
1.11 The CNG cylinders were constructed of ferritic chromium-molybdenum steel
7

wrapped with carbon fibre. They had a maximum fill pressure of 260 bar (less
temperature compensation), settling to the operational pressure of 200 bar.

4
PTIPS employs global positioning systems and radio data communications to deliver information about buses and
their location that is then used to give priority to buses at traffic signals by altering the sequencing and timing of the
signals.
5

The odometer was destroyed in the fire. The distance quoted is that recorded at its last service on 13 July 2011.
6

This distance was obtained from PTIPS data.
7
A stainless steel highly resistant to oxidation, corrosion and stress corrosion cracking.
OTSI Bus Safety Investigation
Fire Involving STA Bus MO4878, Hillsdale, 29 July 2011 4
Each CNG cylinder was fitted with a Ceodeux burst disc pressure valve
wherein the disc breaks if the pressure in an individual cylinder reaches 300
bar. The cylinders were also fitted with a thermal release valve that would
allow the gas to vent if the temperature of the cylinder exceeded 110C
(10). These valves operated independently on each storage cylinder and
would release CNG to the atmosphere in a lateral direction when activated.
The Fire
1.12 The driver was travelling along Denison Road, Hillsdale, returning empty to
STAs Botany Depot at the end of a shift when he was alerted to a problem by
a motorist travelling behind the bus. He stopped the bus and was informed
that there was a fire in the rear of the bus. He then drove approximately 150
metres across the intersection with Beauchamp Road to the first available
safe area and stopped alongside the roadside kerbing. He left the engine
running and went to the rear nearside wheel arch of the bus where he
observed what he described as an orange glow emanating from the area
above the rear mounted engine. He returned to the drivers console and
radioed the STAs Network Control Centre to alert them to the fire, although
he was unsure of his exact location at this time. He then turned off the
ignition. The time was then 7.38 pm.
8

1.13 The driver took the portable 2.5kg dry chemical (powder) extinguisher from its
bracket near the driving position and returned to the rear nearside of the bus.
Another STA driver, who had stopped to assist after overhearing the radio
call, discharged the extinguisher on behalf of the driver under the nearside
wheel arch and towards the engine bay and then departed the scene. (A
number of drivers who were interviewed were of the understanding that they
were not to open the side engine bay hatch for personal safety reasons.)
1.14 The driver returned to the front of the bus where he noticed the interior was
rapidly filling with smoke. Realising that the fire had escalated and spread, he
grabbed his personal bag and moved along the road to a safer position away
from the fire, about 10 metres in front of the bus. Using his mobile phone, he

8
As recorded by the PTIPS. The exact location was determined by the Network Control Centre also using the PTIPS.
OTSI Bus Safety Investigation
Fire Involving STA Bus MO4878, Hillsdale, 29 July 2011 5
called Network Control again to report the escalation of the fire, and then
proceeded to video record the fire on the phones camera.
1.15 When interviewed, the driver stated that he had turned off the ignition but did
not activate either of the emergency gas isolation valves.
Emergency Services Response
1.16 Fire and Rescue NSW was notified by STA Radio and units from Matraville
and Maroubra attended. NSW Police also attended. The first notification was
received by the Matraville Fire Station at 7.44pm and Unit 56 was despatched
immediately. Unit 70 from the Maroubra Fire Station responded at 7.51pm.
At 7.52pm, shortly after the first Fire and Rescue unit arrived, the CNG line at
the rear of the bus ruptured and the CNG ignited. This caused a jet of flame
to extend from the offside of the engine bay out across the road for a distance
of over four metres. Several passing motorists and a motorcyclist narrowly
avoided being injured before traffic movement was stopped.
1.17 Because the CNG was escaping, Fire and Rescue personnel considered it
prudent to evacuate the ORICA Chemical Plant located on the other side of
Beauchamp Road adjacent to the bus. Additional assistance was requested
and Unit 38 responded. The evacuation of the ORICA Plant was completed at
8.06pm. The fire was declared completely extinguished at 9.15pm. See Table
1 for a timed event summary.
7.33pm Passing motorist informs Driver of the fire.
7.37pm Bus stopped at kerb. Driver inspects the rear of the bus.
7.38pm PTIPS identifies bus ignition off.
7.40pm Driver makes initial call advising Network Control Centre of the fire.
7.42pm Driver leaves the bus with an extinguisher.
7.43pm
Another STA bus driver following discharges extinguisher then
departs.
7.44pm Fire & Rescue units receive call out.
7.46pm
Driver has left bus with bag and phones Network Control Centre.
Fire now inside the bus.
OTSI Bus Safety Investigation
Fire Involving STA Bus MO4878, Hillsdale, 29 July 2011 6
7.47pm PTIPS ceases to function.
7.52pm Fire units in attendance. CNG vents.
8.06pm ORICA chemical factory evacuated.
9.15pm Fire extinguished but bus destroyed.
Table 1: Timed event summary

1.18 Fire and Rescue units responded expeditiously to the notification and dealt
effectively with the fire and surrounding environs. While the fire fighters
completed their task efficiently and without sustaining any injuries, they were not
initially informed that the bus was fuelled by CNG.
9
Such prior knowledge would
have been advantageous from a risk management perspective in preparing them
for the potential hazards of venting CNG and exploding CNG cylinders.
Damage
1.19 The roof, windows, all interior fit-out and most of the side panels were
destroyed by the fire. The stainless steel welded frame remained substantially
intact but the sections supporting the roof in the middle of the bus were
severely distorted. The flooring and inspection hatches at and towards the
rear of the bus sustained significant fire damage but the tyres, wheels and
chassis remained intact. The air-conditioning unit housed in a fibreglass pod
and mounted on the roof at the rear of the bus was destroyed. The drivers
console, including steering wheel and dashboard, and the drivers separation
shield were all destroyed as was all internal electrical wiring, the CCTV
cameras and the PTIPS unit.
1.20 The seven CNG storage cylinders housed in the fibreglass pod on the roof
remained intact although the pod itself was destroyed. The CNG cylinders
sustained some minor fire damage to the carbon fibre sheathing but the
individual safety pressure and temperature valves were not damaged and
remained operational. The emergency gas isolation valve mounted on the
roof was not damaged but its activation cable and handle located at the rear
of the drivers position were destroyed.

9
The operator at STA Radio was not in a position to know from its call sign that the bus was powered by CNG.
OTSI Bus Safety Investigation
Fire Involving STA Bus MO4878, Hillsdale, 29 July 2011 7
1.21 The power steering hydraulic fluid and coolant reservoirs and the engine fan
and housing, being constructed predominantly of plastic material, were
destroyed. The electrical system was totally burnt out with electrical shielding
and cable ties melted, allowing remnants of wiring to fall away. Most of the
copper electrical wiring was melted.
1.22 The engine, gear box and turbocharger remained intact although all
supporting hoses, wiring and sensors were destroyed.
OTSI Bus Safety Investigation
Fire Involving STA Bus MO4878, Hillsdale, 29 July 2011 8
PART 2: ANALYSIS
Bus Inspections
2.1 An OTSI investigator inspected the bus at the STAs Leichhardt Depot holding
yard on 30 J uly 2011. Based on the results of this inspection the Chief
Investigator determined that a formal investigation under Section 46BA (1) of
the Passenger Transport Act 1990 (NSW) was warranted. The bus was then
quarantined pending further examination.
2.2 Further inspections of MO4878 were made by OTSI investigators on 1 and 4
August 2011. On these occasions undamaged OC500 LE CNG buses were
also inspected to assist with the identification of systems and parts of the
burnt-out bus. (Four buses were inspected as there are minor variations
between buses of the same model.) On 11 August 2011 two technical
representatives of Mercedes-Benz Australia/Pacific, accompanied by an
engineer from Ingenieurbro Gottwald, a German company engaged by
Mercedes-Benz to determine the cause of the fire, met STA representatives
and OTSI investigators to examine the bus.
2.3 Additional examinations were undertaken on 21 and 22 September 2011
when OTSI investigators requested the engine be removed to enable a more
comprehensive inspection. The engine was removed on 12 October 2011
and samples of coolant and hose connections were removed for analysis. A
Fire and Rescue NSW fire investigator attended the bus on 20 October 2011
in company with STA and OTSI investigators. Following this inspection the
engine was cleaned and a final inspection made on 28 October 2011.
Possible Causes
2.4 The most likely ignition sources of the fire were determined to be:
electrical - shorting of 24 volt wiring;
gas fuel - leak of gas from the supply line or associated components;
oil - leak resulting in oil coming into contact with hot engine components; or
OTSI Bus Safety Investigation
Fire Involving STA Bus MO4878, Hillsdale, 29 July 2011 9
coolant - leak with residual ethylene glycol impregnated into rubber, plastic
or other material and being ignited through contact with hot engine
components.
Electrical
2.5 The bus had two 28 volt / 140amp alternators and a 24 volt / 6.2kW starter
motor. Two 12 volt batteries were located at the offside front of the bus and
were wired in series to provide a 24 volt supply.
2.6 The main wiring loom between the batteries and the starter motor and
alternators was examined for faults. The battery power supply cable had
come into contact with a section of copper piping and short-circuited, burning
through the wall of the pipe. However, this was in front of the gear box
housing and away from the seat of the fire so was determined to be a
consequence of the fire, not the cause.
2.7 The main electrical loom from the batteries was burnt through with the
remnants resting on the drive shaft (see Photograph 2). However, there were
no markings on the drive shaft to indicate this cabling had come into contact
with the shaft while the bus was moving. It was concluded, therefore, that the
fire melted the plastic cable ties holding the wiring harness clear of the engine
thereby allowing the harness to fall onto the drive shaft. Examination of
several other undamaged buses of the same model and age showed the
wiring harness was firmly secured and well clear of the drive shaft.
2.8 Although part of the offside alternator casing had melted, there was no
indication of electrical shorting or of any other problem with the alternator.
Examination of the starter motor revealed only signs of secondary heat
damage and fire exposure; its wiring was mostly intact. The fire could not be
attributed to faults in either of the alternators or the starter motor.
2.9 The PTIPS tracking unit was functioning for some 14 minutes after the fire
started (until 7.47pm) and five minutes before the CNG line vented at 7.52pm.
(This allowed the Network Control Centre to determine the exact position of
the bus.) Examination of the videos of the fire showed that the headlights
remained on until the fire reached the front section of the bus. This confirmed
OTSI Bus Safety Investigation
Fire Involving STA Bus MO4878, Hillsdale, 29 July 2011 10
that the electrical power was still being supplied from the batteries located at
the front offside of the bus after the fire was well underway.


Photograph 2: Electrical loom on tail shaft

2.10 All ancillary wiring in the engine bay and throughout the interior of the bus,
including the drivers console and the dashboard, was either destroyed or
badly damaged.
2.11 From the available video evidence, the drivers interview and inspection of all
electrical components, electrical short circuiting could be discounted as being
the cause of the fire.
CNG Fuel Leak
2.12 CNG differs from Liquid Petroleum Gas (LPG) in that it is lighter than air and
so, when released, will immediately rise and dissipate quickly in the
atmosphere. The bus had seven storage cylinders each fitted with two relief
valves, one thermal and one pressure. In the event of the cylinders being
subjected to excessive heating or experiencing excess pressure build up
OTSI Bus Safety Investigation
Fire Involving STA Bus MO4878, Hillsdale, 29 July 2011 11
within, gas will vent through one or other of the relief valves. Any gas venting
near a naked flame will ignite.
2.13 Examination of the bus found that the CNG fuel line was intact between the
supply cylinders and the engine high pressure solenoid valve where a male
threaded fitting manufactured from stainless steel had been torn out of a
brass female fitting, stripping the internal brass thread. This component
failure can be attributed to the combined effect of pressure in the gas supply
line and heat from the fire, given that brass has a higher coefficient of thermal
expansion than stainless steel.
10
The fuel line, with the stainless steel fitting
attached, was bent well away from the brass fitting indicating that the line had
been under considerable pressure when the fitting failed (see Photograph 3).

Photograph 3: Ruptured CNG line-compared with an undamaged line


10
Coefficient of expansion for brass is 18.5 x 10
-6
m/m K while stainless steel is 16 x 10
-6
m/m K. (Information sourced
from http://www.engineeringtoolbox.com/linear-expansion-coefficients-d_95.html)
OTSI Bus Safety Investigation
Fire Involving STA Bus MO4878, Hillsdale, 29 July 2011 12
2.14 When the fitting failed, CNG vented through the ruptured line and was ignited
by the fire. This caused a jet of flame to shoot out from the bus and partially
across the roadway. The event was captured on the video recorded by the
driver on his mobile phone and similarly by nearby witnesses who
subsequently posted their video footage on YouTube. All videos show the
back of the bus alight along with the interior and engine bay before the gas
ignited.
2.15 The venting through the ruptured line at the solenoid valve occurred 19
minutes after the fire was reported to the driver by the motorist following the
bus. Fire and Rescue NSW units arrived on scene just before the venting
occurred.
2.16 As the videos showed no venting to be occurring from the relief valves on the
gas storage cylinders and all cylinders were empty when inspected, it is
concluded that all the gas was consumed through the ruptured line at the
solenoid valve. Had the emergency gas isolation valve been activated, the
cylinders would have vented separately through their relief valves and to the
sides of the cylinders when the pressure and/or temperature rose to critical
levels. Based on the fact that the bus had travelled 97 km since being
refuelled the previous day, it is estimated the pressure in the CNG cylinders
would have been approximately 188 bar when the fire started.
2.17 The driver did not notice any loss of power or misfiring of the engine prior to
the incident which might have indicated a leak in the gas supply to the engine.
A report of the bus misfiring at low speeds and being sluggish was made on
27 April 2011. This was identified as being due to a gas leak at the gas filter
on the high pressure inlet side of the supply which was duly repaired at the
Botany workshop.
11

2.18 Any excess gas not used by the engine is vented unpressurised to the
atmosphere above the roof line on the offside rear of the bus through a
stainless steel pipe. A fitting on this pipe, after the main relief valve, was
found to be loose by one complete turn. A gas leak from this fitting is only
likely to have occurred intermittently, if at all, during normal operation, and

11
Work Order PC 7309 dated 27 April 2011.
OTSI Bus Safety Investigation
Fire Involving STA Bus MO4878, Hillsdale, 29 July 2011 13
only if there was an excess of CNG not required by the engine. Additionally,
there was no potential ignition source in the immediate area of the fitting. It
was concluded, therefore, to be most unlikely that this loose fitting contributed
to the cause of the fire.
2.19 In its report, Ingenieurbro Gottwald concluded that, when the solenoid valve
was replaced, the high pressure line fitting was screwed in at an angle (cross-
threaded) eventually loosening such that gas could escape and ignite on
contact with a spark or hot components in the engine bay.
12
Evidence
supporting a contrary view would appear to be:
the time that had elapsed since the solenoid valve was replaced - 16
J anuary 2008;
that a leak would have become apparent by adversely affecting the
engines performance;
that no leak or fault was detected in the annual gas system inspections;
the fire pattern;
the drivers observations; and
the progress of the fire as recorded on videos.
Oil leak
2.20 There was no oil residue or obvious effects from fire on the underside of the
engine. The engine block, sump and cylinder heads survived intact and
showed no signs of oil loss. The lines to the oil filters were undamaged and
the plastic covers on the filter housing, located higher on the engine, were
only partially burnt.
2.21 The hydraulic reservoir for the power steering was destroyed in the fire.
However, there was a residue of hydraulic oil present on the offside of the
engine which had come from the hydraulic steering pump inlet connection.
This hydraulic oil had flowed vertically downwards and not trailed towards the
rear of the engine, indicating it was deposited after the bus had caught fire
and stopped. It is considered most likely that heat from the fire caused the
washer at the pump inlet connection to fail thus allowing oil to leak out.

12
Ingenieurbro Gottwald, Fire damage, EXPERT REPORT E 0811098, 17 October 2011 [Translation]
OTSI Bus Safety Investigation
Fire Involving STA Bus MO4878, Hillsdale, 29 July 2011 14
2.22 The engine sump was drained and the 33 litres of oil obtained was found to
be clean and of the correct volume in accordance with the manufacturers
specifications. Examination of the incident site indicated there had been no
major oil leak onto the bitumen road surface at, or leading up to that location.
2.23 The oil supply pipe to the turbocharger was removed and examined by an
independent metallurgist contracted by the STA. This examination found no
evidence of fractures or pin holes in the oil supply pipe which would have
allowed oil to spray out onto a hot surface.
2.24 The rubber air inlet hose to the turbocharger was burnt on the top surface
only. The hose was removed to permit an examination of the turbocharger
fan blades. They were found to be intact and the rotor could be spun easily
with finger pressure. This indicated that there had not been any substantial
interruption to either coolant supply or oil lubrication which would have
resulted in the turbocharger rotor seizing or being damaged. It was concluded,
therefore, that the turbocharger could be eliminated as being the source of the
fire.
Coolant
2.25 Examination of the interior section of the heat exchanger on the offside of the
bus showed a clear line where the lower section had not melted, indicating
that the coolant in the lower section had prevented it from melting. The
coolant header tank mounted at the rear of the bus had completely melted
indicating that the reservoir was empty prior to the fire. In contrast, the plastic
windscreen washer bottle located in the front of the bus remained intact and
was full of water, although all other components around it had been destroyed
(see Photograph 4). The conditions as described are indicative of the
possible loss of coolant in the heat exchanger and coolant reservoir before
the fire commenced. A significant loss of coolant would result in a substantial
rise in the operating temperature of the engine.
OTSI Bus Safety Investigation
Fire Involving STA Bus MO4878, Hillsdale, 29 July 2011 15

Photograph 4: Windscreen washer bottle

2.26 With the engine removed from the bus, a more detailed inspection was made
to determine the cause of the fire. Examination of the coolant system showed
the flexible rubber connection between the coolant return line from the
turbocharger and a T fitting was destroyed by the fire (see Photograph 5).
The steel piping from the turbocharger was 18mm out of alignment with the T
fitting to which it was connected. This misalignment would have placed
additional stress on the rubber hose, exacerbated by engine vibration. The
coolant return line was supposed to have been replaced on 14 December
2010 but was not (see Servicing and Maintenance).
2.27 There was also a split and fire damage to the flexible rubber reduction fitting
on the main coolant supply pipe running along the top of the engine block,
near the engine compressor (see Photograph 6). The main coolant reduction
hose had also been severely damaged by fire on the top surface. It could not
be determined if coolant leaking from the split in this hose was the cause of
the fire or was a consequence of the fire.



OTSI Bus Safety Investigation
Fire Involving STA Bus MO4878, Hillsdale, 29 July 2011 16




Photograph 5: Coolant return hose fitting misalignment


Photograph 6: Main coolant line reduction hose

OTSI Bus Safety Investigation
Fire Involving STA Bus MO4878, Hillsdale, 29 July 2011 17
2.28 On 11 August 2011, the flexible rubber connection between the coolant return
line from the turbocharger and a T fitting was found to have split on another
OC500 LE CNG bus. This split in the hose resulted in a considerable amount
of coolant being sprayed onto the engine (see Photograph 7). On this
occasion the driver received a low coolant alarm and responded immediately
by turning off the engines ignition. He reported observing a large amount of
steam emanating from the top of the engine. It is believed this steam was
caused by the water content in the coolant boiling off on coming into contact
with the hot surface of the engine.








Photograph 7: Split coolant return rubber connection

2.29 After the coolant leak had been examined by OTSI and the Mercedes-Benz
investigators, the bus was left standing for several hours before being
restarted and driven a short distance (about 200 metres) from the holding
area to the depot workshop. On arrival at the workshop, it was found that the
residual ethylene glycol from the coolant had pooled on the engine and had
ignited while the bus was being moved. The turbocharger coolant return line
hose on this bus was identical to the one on MO4878, having also not yet
been replaced.
Split hose connection
OTSI Bus Safety Investigation
Fire Involving STA Bus MO4878, Hillsdale, 29 July 2011 18
2.30 The recommended coolant for use on OC500 LE CNG model buses was a
mixture of 50% water and 50% ethylene glycol. A sample of the coolant was
taken from MO4878 on 12 October 2011 and subjected to chemical analysis
at the University of NSW (UNSW) Chemical Consulting Laboratory, Mark
Wainwright Analytical Centre. It was determined that the specific gravity of the
coolant was approximately 1.08 with a water content of 66%. There is no
plausible explanation as to why the water content of the sample was higher
than 50% other than that the header tank may have been topped up at some
stage with fresh water rather than coolant mixture.
2.31 The Western Australia Public Transport Authority commissioned a consulting
engineers report into a fire which destroyed a Transperth Mercedes-Benz
OC500 LE CNG bus on 15 December 2009. This report concluded: The
fairly high probability that there was a glycol leak and the somewhat makeshift
nature of the modified T piece gives rise to the possibility that this pipe may
be implicated in this fire.
13
The circumstantial evidence supporting the
conclusion was a low coolant level alarm, a trail on the road leading to the
bus, judged to be most probably coolant, and the drivers report of whitish
smoke billowing from under the nearside of the engine compartment.
2.32 An analysis of the characteristics of ethylene glycol-based coolants indicates
that under certain conditions coolant can ignite.
14
This occurs when the water
content of the coolant is evaporated off leaving pooling of the residual
ethylene glycol. It can also ignite in circumstances where the glycol
impregnates other materials such as lagging or shielding and is then exposed
to a heat source and air.
2.33 With the engine removed from MO4878, investigators were able to determine
that the initial seat of the fire was located on top of the engine near where the
compressor is mounted. This is immediately below the rear floor hatch. The
initial seat of the fire was also in the immediate proximity of the small hose
connection on the coolant return line from the turbocharger.

13
Martin E Simms & Associates Pty Ltd, Report on a Fire in CNG Bus TP1854, Report Reference 4328-MES-02, dated 1
February 2010.
14
Hull WC et al, Analysis of Ethylene Glycol-based Engine Coolant as a Vehicle Fire Fuel, International Symposiumon
Fire Investigation Science and Technology, 2008.
OTSI Bus Safety Investigation
Fire Involving STA Bus MO4878, Hillsdale, 29 July 2011 19
Servicing and Maintenance
2.34 In J uly 2010 Mercedes-Benz ordered the upgrade of a number of M447 hLAG
engine components.
15
The work involved included the replacement of:
the turbocharger heat shield,
the oil feed lines to the turbocharger,
the manifold heat shield,
the air compressor oil feed line, and
the coolant return line from the turbocharger to the compressor.
2.35 Mercedes-Benz issued a Technical Information Bulletin (TS-CV-20-11) in J uly
2010 advising that the coolant hose secured to the T piece from the
compressor coolant pipe and the associated hose clamps had been
superseded. The replacement of these parts was incorporated with other
work to be completed under Vehicle Safety Recall RC 832 Turbocharger and
Air Compressor Modifications which was dated 20 J uly 2010.
2.36 On 19 September 2011, Mercedes-Benz Australia/Pacific Pty Ltd advised
Mercedes-Benz Huntingwood that it would appear that there was some
confusion during the initial release of this Recall [RC 832] and it may not have
been completed on all vehicles. On 23 September 2011, Mercedes-Benz
advised the STA that Mercedes-Benz had instructed their dealership to
complete the work on STA buses. The STA states it was not aware of the
requirement until then. Mercedes-Benz explained that STA buses were not
included in the original list of vehicles to have the coolant pipe replaced.
Mercedes-Benz further explained that further research has shown that TS-
CV-20-11 is applicable to the STA busses which would have included MO
4878 if it had survived the fire.
2.37 An examination of the service records for MO4878 since its introduction into
service showed that all regular servicing and maintenance had been carried
out as recommended by the manufacturer, other than the changeover of the
coolant connecting hose as indicated in RC 832. There was no indication
from the service records that a lack of maintenance or servicing could have
contributed to creating a potential fire risk.

15
Recall Notices - 0C500 LE CNG M447 hLAG RC722, RC766 and RC832.
OTSI Bus Safety Investigation
Fire Involving STA Bus MO4878, Hillsdale, 29 July 2011 20
Development of the Fire
2.38 Examination of the fire pattern on the top of the engine, the sub-frame and
under floor areas with the engine removed, established that the seat of the fire
was located under the rear floor inspection hatch. This was the area of most
severe damage and greatest heat effect on the engine metal. Hoses in the
area that were not destroyed were damaged on the surfaces exposed to the
fire. Also in this area was a considerable amount of electrical wiring to the
electronic control management unit, all of which had been wrapped in plastic
binding, which was consumed in the fire.
2.39 The turbocharger coolant return line connecting hose and connecting
reduction hose on the main coolant line were located in the area immediately
below the hatch. If a coolant leak were to occur in this area, the fluid could
pool on top of the engine block as was the case with the bus that suffered a
split connecting hose on 11 August 2011.
2.40 There was no corresponding fire pattern to the rear of the bus hatch,
especially near the CNG lines or on the sill between the engine bay and the
rear window, which would indicate that the initial seat of the fire was in this
area. The damage to various fittings and hoses attached to the engine was
consistent with the effect of a fire commencing in the area under the rear floor
hatch.
2.41 Analysis of the fire pattern on the underneath of the floor of the bus and on
the engine indicated that the fire initially entered the inside of the bus through
the small rearmost floor hatch which had completely burnt through (see
Photograph 8). The second last floor hatch had also been severely damaged
by fire although not burnt through completely. The hatch under the rear
passenger bench seat was also severely damaged although there was a
section of stainless steel shielding under the hatch.
2.42 As evidenced by the fire pattern radiating from the small hatch, the fire spread
into the interior of the bus around the hatch then along both sides of the rear
passenger seat, to both sides of the bus and towards the roof. This is
consistent with the video evidence, the drivers statement and there being
comparatively limited damage to fibreglass side panelling.
OTSI Bus Safety Investigation
Fire Involving STA Bus MO4878, Hillsdale, 29 July 2011 21

Photograph 8: Rear floor hatches

2.43 The floor hatches were not protected with stainless steel shielding like the
other areas of the engine bay except for the rear seat hatch which, despite
having some shielding, was still severely damaged. Also, the floor hatches
are made of much thinner plywood than the rest of the floor; 12mm compared
to 16.2mm. These bus floor hatches provided the area of least resistance to
the fire and allowed the flames into the interior of the bus.
Mercedes-Benz 0C500 LE CNG Bus Fire in Australia
2.44 STA experienced one other fire in its fleet of 255 Mercedes-Benz OC500 LE
CNG buses between J une 2008 and J uly 2011.
16
The only other known
operator currently using this model of bus in Australia is Transperth which has
480 operating in the Perth metropolitan area. Transperth has experienced 11
fires in this model bus since the commencement of their introduction into
service in 2005, although all these fires occurred in 2008 and 2009. Four
buses were destroyed while fires on six were extinguished by the bus driver
before major damage was caused. The remaining bus was saved by a

16
STA bus MO1813 experienced a fire on 27 August 2008.
OTSI Bus Safety Investigation
Fire Involving STA Bus MO4878, Hillsdale, 29 July 2011 22
recently fitted fire suppression unit.
17
Of the buses destroyed, three fires were
attributed to faulty oil supply pipes to the turbocharger and the fourth to a
coolant leak.
Other Safety Issues
Driver Training
2.45 At no stage did the driver shut off the CNG supply which could have been
done either internally from behind his seat or externally at the rear of the bus.
Depriving the fire of this major source of fuel may have impeded its rate of
development, thus giving fire fighters greater opportunity to contain and
extinguish it.
2.46 Although the bus was equipped with a portable fire extinguisher, it appears
that instructions to drivers on how to respond to a bus fire were unclear.
Some drivers indicated that they were told not to open side or rear engine
hatches for the sake of their own safety. Some said they did not have a key to
open the engine bay. Yet others indicated that they thought they should open
the engine bay and had the appropriate key.
2.47 The effectiveness of a dry powder extinguisher relies on the powder
blanketing the fire from above. Without opening the engine bay hatches,
drivers are unable to accurately direct the dry powder at the seat of a fire. An
alternative is to discharge the extinguisher under the sides and generally
towards the location of the engine area. This is unlikely to be effective as is
evidenced in this instance.
2.48 Residue of the powder from the extinguisher remained evident on areas of the
chassis and other components indicating that the discharge of powder was
not effective in blanketing the fire source on top of the motor. The engine,
chassis, sub-frame and engine appendages blocked the powder from its
target.
2.49 The investigation found that there were deficiencies in the training of drivers in
handling this type of incident. They had not received clear instructions or, in
some cases, any instructions to isolate the CNG supply and evacuate

17
Transperth has fitted all buses in the fleet with fire suppression units as a result.
OTSI Bus Safety Investigation
Fire Involving STA Bus MO4878, Hillsdale, 29 July 2011 23
passengers immediately before attempting to fight the fire. Additionally, they
had no basic training in first attack fire fighting procedures, especially
instruction in the use and effectiveness of dry powder extinguishers.
2.50 A structured training programme in emergency procedures for drivers on each
type of bus was lacking. Long term employees had received their initial
training on other bus models which ran on different fuel but no subsequent
refresher training. Comprehensive conversion training in emergency
procedures was not provided at all STA depots when the CNG buses entered
service.
Network Control
2.51 At no time during radio communications between the Network Control and the
driver did the operator ask the driver if the bus was CNG fuelled, nor did he
remind him to isolate the gas supply. Although radio operators cannot be
expected to know by bus registration the make and fuel type of every bus in
the fleet, it would be advantageous in the case of fire if they could establish if
the bus is CNG powered and, if so, remind the driver to isolate the gas supply.
2.52 It could be critical for emergency services to be forewarned of particular
hazards they are likely to encounter when deployed. With CNG fuelled bus
fires, there is the danger of jets of venting gas igniting or storage cylinders
exploding. The danger template is therefore larger and may require greater
and more diverse resources to protect lives and property.
Dangers of CNG Fuel in Fire Incidents
2.53 The use of CNG has been growing in transit and other fleet vehicles in
response to increasingly stringent emissions standards. While CNG has
some benefits relating to reduced emissions compared with other fuels, its
use also introduces different fire safety risks than those associated with more
conventionally powered vehicles. A study published in 2004 concluded that
CNG school buses could be expected to be significantly more prone to fire
fatality than diesel powered buses.
18


18
Chamberlain, S Development of a Physics of Failure Model and Quantitative Assessment of the Fire Fatality Risks of
Compressed Natural Gas Bus Cylinders, PhD Dissertation, U.Maryland, 2004.
OTSI Bus Safety Investigation
Fire Involving STA Bus MO4878, Hillsdale, 29 July 2011 24
2.54 Catastrophic rupture of a pressure vessel containing CNG will result in a rapid
increase in the volume of the gas. This rapid mixing with air in the presence of
an ignition source will form a fireball as soon as a flammable mixture is
achieved. Also, a jet flame can result from the pressurised release of CNG
from a crack in a line in the presence of an ignition source as was the case in
this incident.
2.55 CNG cylinders can explode if overheated or over pressurised. In Queensland
there have been two recent incidents of CNG cylinders exploding on buses,
one in 2008 and one in 2012. In both cases, other vehicles over 100 metres
from the site of the explosion were damaged.
19
Over-pressurisation or
cylinder failure has been attributed as the cause on both of these occasions.
2.56 In August 2011 in India, five people, including two children, were killed when
the CNG cylinder of a bus they were travelling on exploded. The bus caught
fire immediately after the blast. In this incident defective manufacturing of the
CNG cylinder was indicated as the cause.
2.57 In December 2011, a CNG powered bus suffered a catastrophic failure of a
cylinder while stopped at traffic lights in Seoul, South Korea. The bus was
torn apart, nearby windows were shattered and 17 people were injured
including passengers, riders and pedestrians. Seoul's bus fleet consists of
approximately 95% CNG powered buses.
Remedial Actions
2.58 In response to this incident the STA implemented a number of remedial
actions:
All Mercedes-Benz OC500 LE CNG and 0500 diesel powered buses were
immediately inspected and a weekly checking program initiated.

19
CNG storage cylinders involved in the incidents in Queensland, India and South Korea were Type 4 cylinders
comprising of a non-metallic liner over which an overwrap of carbon fibre or fibreglass is applied in a full wrapped
pattern over the entire liner. The STA CNG buses are fitted with Type 2 cylinders comprising of a metallic liner over
which an overwrap of carbon fibre or fibreglass is applied in a hoop wrapped pattern over the liners cylinder sidewall.
They are rated at a higher burst pressure than full composite cylinders (even with damage to the outer wrapping) but
are heavier and so increase the tare weight of a vehicle.
OTSI Bus Safety Investigation
Fire Involving STA Bus MO4878, Hillsdale, 29 July 2011 25
A training programme was implemented for all drivers incorporating the
need to identify the fuel type of their bus when reporting a fire or thermal
incident and, on CNG buses, the need to immediately isolate the CNG.
Network Control operators were instructed to remind all drivers when they
reported incidents to isolate the CNG if applicable.
Network Control operators were instructed to determine the fuel supply of
the bus for the information of emergency services when an incident is
reported.
A review has been conducted of the instructions to drivers as to correct
procedures for evacuation of passengers and for use of fire extinguishers.
All OC500 LE CNG buses have had the return coolant line and connecting
hose fitting replaced.
Tenders have been called for the retrofitting of fire suppression systems
on all OC500 LE CNG buses.
2.59 The STA has stated its intention to have fire suppression fitted to all high risk
vehicles in the future, both diesel and CNG fuelled. Further, STA is of the
view that the supply and fitting of fire suppression should be included as part
of the standard specifications for buses.

OTSI Bus Safety Investigation
Fire Involving STA Bus MO4878, Hillsdale, 29 July 2011 26
PART 3 FINDINGS
3.1 The investigation found that the most likely cause of the fire on STA bus
MO4878 was coolant being sprayed onto the engine from a split hose
connection on the turbocharger coolant return line to the compressor. The
water content of the coolant evaporated on the hot surface of the engine
allowing the residual ethylene glycol to crystallise and ignite. With the loss of
coolant from the engine system, the external engine temperature to which the
coolant was exposed would have risen progressively.
3.2 As the fire intensified, it burnt through the rear floor hatch and ignited the
seating and other combustible interior materials. Although the timber plywood
floor hatches were the most vulnerable area, they were not protected with
stainless steel shielding like other areas of the engine bay.
3.3 Some 19 minutes after the initial fire was detected, the connection of the CNG
line at the solenoid valve succumbed to the intense temperature and resultant
increase in pressure and vented in a jet of flame.
3.4 At no stage did the driver shut off the CNG supply which could have been
done either internally or externally. Depriving the fire of this major source of
fuel may have impeded its rate of development, thus giving fire fighters
greater opportunity to contain and extinguish it.
3.5 The dry powder portable extinguisher with which the bus was equipped was
not effective as it could not be directed at the fire.
3.6 There were deficiencies in the training of drivers in handling a vehicle fire, in
the provision of conversion training on the introduction of a new make or
model of bus, and in providing refresher training.
3.7 It was identified that Network Control personnel could assist in emergencies
involving gas powered buses by reminding drivers to shut off fuel supplies,
and by forewarning emergency services personnel of any known additional
hazards they may confront at the fire site.
3.8 The nature and extent of remedial action undertaken as a result of this
incident precludes the need for recommendations for further action by the
State Transit Authority.
OTSI Bus Safety Investigation
Fire Involving STA Bus MO4878, Hillsdale, 29 July 2011 27
PART 4 SUBMISSIONS AND ACKNOWLEDGEMENTS
Submissions
The Chief Investigator forwarded a copy of the Draft Report to the Directly Involved
Parties (DIPs) to provide them with the opportunity to contribute to the compilation of
the Final Report by verifying the factual information, scrutinising the analysis,
findings and recommendations, and to submit recommendations for amendments to
the Draft Report that they believed would enhance the accuracy, logic, integrity and
resilience of the Investigation Report. The following DIPs were invited to make
submissions on the Draft Report:
Custom Coaches Pty Ltd
Fire & Rescue NSW
Independent Transport Safety Regulator
Mercedes-Benz Australia/Pacific
NSW State Transit Authority
Rail Tram and Bus Union NSW Branch
Transperth
Transport for NSW

Submissions were received from all but the Independent Transport Safety Regulator
and Transperth.
The Chief Investigator considered all representations made by DIPs and responded
to the author of each of the submissions advising which of their recommended
amendments would be incorporated in the Final Report, and those that would not.
Where any recommended amendment was excluded, the reasons for doing so were
explained

Acknowledgements
OTSI thanks the following organisations for their assistance throughout this
Investigation:
Custom Coaches NSW
Fire and Rescue NSW- Fire Investigation and Research Unit
OTSI Bus Safety Investigation
Fire Involving STA Bus MO4878, Hillsdale, 29 July 2011 28
Mercedes-Benz Australia/Pacific Pty Ltd
State Transit Authority Sydney Buses NSW
Transperth- Public Transport Authority- Perth WA
Transport Safety Victoria
University Of New South Wales Mark Wainwright Analytical Centre