WASHINGTON When a motorcoach carrying nursing home residents out of the path Hurricane Rita caught fire in September 2005, leading to the death of 23 elderly passengers, the brightest investigative light in the federal government was turned on the bus operator, Global Limo Inc. of Pharr, Texas.

What that spotlight revealed was a motorcoach operator that blatantly ignored federal safety regulations and mostly shunned any kind of coach maintenance until something broke or failed.

The companys business, safety and operational practices were analyzed in significant detail last month when the National Transportation Safety Board conducted its formal accident report meeting on the fire.

For eight hours, the board listened to and examined information and data compiled by NTSB investigators and staff members who spent 17 months investigating the incident and the circumstances leading up to it.

What emerged from the meticulous work was the picture of a company that, in the words of NTSB board members, "violated every rule in the book" and was unsafe "by any standard," and a company owner, James Maples, who fostered "an attitude of noncompliance that permeated the company."

NTSB investigators uncovered problems in virtually every area of Global Limo, from maintenance, to safety management, to hiring, to record keeping, to training, to regulatory compliance, to administration, and to failing to uphold the public trust that is fundamental to operating a passenger-carrier business.

Maintenance

* There was no evidence Global Limo had a systematic or scheduled maintenance program. Instead, "this company had a systematic maintenance problem," said one board member.

* The company did not document maintenance of its vehicles.

* Pre-trip inspections were not performed. Maples both dumbfounded and outraged NTSB board members, two of whom are former commercial pilots, when he told investigators he "didnt pay his drivers to conduct pre-trip inspections." NTSB Vice Chairman Robert Sumwalt said he was an airline pilot for 24 years and no one ever paid him to check his plane. But he did it every time before climbing into the cockpit.

* Recent maintenance before the fire was performed at a Volvo truck dealership. No evidence was presented at the hearing that the mechanics at the truck dealership ever saw a bus maintenance manual, and questions were raised as to whether the mechanics even checked the areas that led to the fire.

* Maintenance done by Global Limo invariably was repair work, not preventative. Typical was the work done in August to an air tank. The spot repairs were made at a mobile repair vehicle Motor Coach Industries was operating in the wake of Hurricane Katrina. It was hardly the place or time for any kind of thoroughness.

* A drive tire was installed on a Global Limo bus that was rated at 4,000 pounds less than it should have been.

* When the driver of the coach that burned tried to use the on-board fire extinguisher, he wasnt able to free it from its mounting.

Regulatory Compliance

* The company routinely switched license plates between buses, one consequence of which was that investigators could not tell which buses had actually been checked at roadside or destination inspections since tags and vehicle IDs were never compared.

* Global Limo drivers were put out of service 50 percent of the time when stopped for roadside or destination inspections.

* When Global Limo buses underwent roadside or destination inspections, the company never returned the inspection forms as federal regulations require.

* There was no brake certification on file for the mechanic that Global Limo employed.

* Global Limo did not perform the drug or alcohol testing of the driver after the fire as required by federal rules.

* Global Limo "gamed the system" and "skirted the rules," said two NTSB board members.

Hiring Practices

* The driver of the burned coach was an illegal alien; he was hired anyway.

* The driver did not speak, understand or read English. The driver could not read changeable road signs or vehicle-related documents. The driver could not communicate what milepost marker the coach was near when an attendant on the bus called 911 to report the fire, possibly delaying emergency help. The driver could not communicate with the mechanic who changed a tire on the coach a few hours before the fire.

* Because the driver didnt speak English, he couldnt present himself as an authority figure when the fire crisis occurred.

* The driver had a Mexican CDL, but no U.S. CDL. The Mexican CDL did not note the drivers diabetic condition.

Safety/Driver Training

* The driver of the coach that burned had never been trained on the bus he was operating.

* Driver training at Global Limo consisted of popping videos into a VCR and letting drivers watch. The videos were in English, none were in Spanish.

* The driver got two speeding tickets in the months leading up to the fire. He never showed up for his court dates.

Administration

* The bus that burned was not registered in Texas; it had no valid tags.

* Global Limo was hired by Bus Bank for the trip that resulted in the fire. Even though Bus Bank requires the companies it uses to complete a questionnaire about their operation, Global Limo never returned the questionnaire.