Insights, fallout from NTSB's final report on East Palestine derailment
6/27/2024
By Julie Sneider, Senior Editor
Sixteen months after a Norfolk Southern Railway train carrying hazardous materials derailed in East Palestine, Ohio, the National Transportation Safety Board (NTSB) met June 25 to review its investigators’ 37 findings in the case and issue dozens of safety recommendations to prevent similar accidents from happening.
During a daylong meeting at East Palestine High School, board members announced that investigators concluded a rail car’s defective wheel bearing caused the derailment and subsequent hazardous material release during the first week in February 2023. NTSB investigators said the bearing on a hopper car failed and overheated, causing 38 of the train’s rail cars to derail and some to catch fire. Eleven of the cars were carrying hazardous materials.
Overheated wheel bearings are a common cause of rail accidents, investigators told the board. The NS train crew did not receive a hot-bearing warning until the train passed over a detector in East Palestine as the overheated bearing was about to cause the axle to fail, they said. Although the crew began to slow the train using dynamic braking, it was too late and the derailment occurred.
Days later, a decision was made locally to conduct a vent and controlled burn involving toxic chemicals in five of the train’s tank cars.
Investigators: Vent and burn unnecessary
NTSB investigators said the decision by the local incident commander to conduct the vent and burn was based on incomplete and misleading information provided by NS officials and contractors. The procedure wasn’t necessary to prevent a tank-car failure, the investigators determined.
The NTSB faulted NS for concluding that vinyl chloride being transported in some of the cars was at risk of exploding in the immediate days after the derailment. That conclusion resulted in the vent and burn of five cars, which led to the release of toxic chemicals and a giant plume of dark smoke that hovered ominously over the area.
“The absence of a fatality or injury doesn’t mean the presence of safety.” — NTSB Chair Jennifer Homendy National Transportation Safety BoardThe controlled burn required a community evacuation and prompted East Palestine residents to be concerned about long-term health impacts of the chemical release.
Vent and burn is a seldom used procedure and should be used only when there is a high probability of tank-car failure, according to NTSB investigators. In this case, the action was approved by NS and its contractors based on misinterpreted information and disregarded evidence, NTSB staff said. Investigators found that an alternative option to vent and burn was overlooked.
“Some have sought to minimize the wide-ranging impacts of this derailment, pointing to the fact that there were no fatalities or injuries. For this, we are certainly grateful, but the absence of a fatality or injury doesn’t mean the presence of safety,” NTSB Chair Jennifer Homendy said as she opened the June 25 meeting. “We don’t wait for death or injury to occur. We bring safety issues to the forefront and make recommendations that, if implemented, would prevent the next train derailment and fire.”
The board reviewed the key safety issues raised during investigation, including wheel bearing failures and detection; the initial emergency response; hazmat and tank-car derailment performance; and the vent-and-burn procedure performed by NS and its contractors. NTSB members approved the investigators’ 37 findings before voting on over two dozen safety measures.
“We are here to ensure that the lessons learned from this derailment will lead to meaningful change so no other community has to relive the challenges faced by the people of East Palestine,” said NTSB member Michael Graham, who was at the derailment site when the board’s investigators arrived.
Use of DOT-111s added to the disaster
The board also agreed that the continued use of DOT-111 tank cars to transport flammable liquids and other hazardous materials contributed to the severity of the release. During the derailment, three DOT-111s were mechanically breached, releasing flammable and combustible liquids that caught fire, investigators said. The fire spread and exposed other tank cars to heat, which led to the decision to conduct the vent and controlled burn.
The DOT-111 tank car is being phased out of flammable liquids service because of its “long record of inadequate mechanical and thermal crashworthiness,” according to an NTSB statement.
As a result of the investigation, the NTSB issued new safety recommendations to NS; the U.S. transportation secretary; the Federal Railroad Administration; the Pipelines, Hazardous Materials Safety Administration; the state of Ohio; the Association of American Railroads, Columbiana County Emergency Management Agency; the Chlorine Institute; the International Association of Fire Chiefs; the International Association of Fire Fighters; the American Chemistry Council; Oxy Vinyls LP; and the National Volunteer Fire Council.
The safety issues addressed in the NTSB recommendations include:
• failure of wayside monitoring systems to diagnose a hot wheel bearing in time to prevent a derailment;
• inadequate emergency response training for volunteer first responders;
• hazardous materials placards that burned away, preventing emergency responders from immediately identifying hazards;
• a lack of accurate, timely and comprehensive information passed to local incident commanders and state officials; and
• the continued use of DOT-111 tank cars in hazmat service.
An abstract of the final report, which includes all safety recommendations, can be read here. The board will publish the full final report in the next few weeks.
NS responds
After the NTSB meeting, NS officials said the company has already begun some of the board’s safety recommendations.
“We share the commitment and over the last 16 months have implemented many enhancements and technologies to make our railroad even safer,” NS officials said in a prepared statement.
“We are here to ensure that the lessons learned from this derailment will lead to meaningful change so no other community has to relive the challenges faced by the people of East Palestine.” — NTSB Member Michael Graham National Transportation Safety BoardAmong the NTSB’s recommendations, the railroad already acted to enable immediate availability of train consist information to first responders. NS also encourages contractors to share information needed to make emergency response decisions.
Moreover, the Class I has “substantially addressed” the FRA’s recommendations from its 2023 assessment of the railroad’s safety culture, NS officials said.
“As a result of these actions and others, Norfolk Southern's mainline accident rate declined 38% last year to industry leading levels,” they said. “We will move quickly to compare the NTSB's recommendations to our current protocols and will implement those that advance our safety culture.”
NS officials were encouraged that NTSB investigators determined the train crew had been operating below the track speed limit and had been handling the train properly prior to the derailment. Once the crew was alerted by the wayside detector, they acted appropriately by beginning to stop the train.
“We resolved not to wait for the NTSB's final report before taking decisive action," said NS Chief Safety Officer John Fleps. "We will continue to build on our strong safety culture through partnership and innovation to be the gold standard of safety for the rail industry."
Among the safety measures NS has implemented since the derailment:
• The company became the first railroad to partner with the RapidSOS digital platform that connects devices over 16,000 emergency response agencies to immediately provide first responders with real-time access to train consists, train locations and emergency response protocols;
• NS continued to advocate for phasing out inferior customer-owned DOT-111 tank cars;
• The Class I launched and implemented a six-point safety plan that includes installing 187 additional hot bearing detectors, reducing core network average distance between detectors to about 12 miles; quadrupled acoustic bearing detectors; developed and deployed digital train inspection portals; and invested in next-gen inspection technology;
• NS has continued to invest in training first responders on hazmat response;
• The railroad worked with labor unions to become the first Class I to join the FRA’s Confidential Close Call Reporting systems; and
• The company contracted AtkinsRealis to audit NS safety and implement a two-to-three-year roadmap of additional safety measures.
Regarding the NTSB’s determination that the vent and burn was unnecessary, NS officials said it was implemented after other alternatives were considered. The railroad and its contractors recommended the vent and burn to the Unified Command “as the only option to protect the community from a potential catastrophic explosion,” NS officials said. The decision was developed under guidance from two specialized firms certified by the Chlorine Institute to respond to vinyl chloride emergencies.
NS and its contractors received conflicting information from Oxy Vinyl, the vinyl chloride manufacturer, as to whether polymerization was or could be occurring, the company stated. The company does not agree with the NTSB conclusion that the company “withheld” Oxy Vinyls’ views from the Unified Command at the derailment site.
“The vent and burn effectively avoided a potential uncontrolled explosion. There was no loss of life and contractors took steps to manage environmental impact,” NS officials said.
Additionally, NS announced June 24 that it would convene a “Vent and Burn Workgroup” to integrate what it has learned since East Palestine about where a vent and burn may be necessary. The workgroup is being developed in accordance with the company’s U.S. Department of Justice and Environmental Protection Agency consent decree, which is awaiting court approval.
Last month, NS reached an agreement on the consent decree with DOJ and EPA to resolve their claims and investigations arising from the derailment. The decree calls for NS to pay a $15 million civil penalty and reimbursing the EPA for its full response expenses, which were about $57 million through Nov. 30, 2023, as well as subsequent response costs.
AAR reviewing the report
Meanwhile, the AAR is reviewing the NTSB’s findings and safety recommendations to determine next steps to advance safety, association officials said in a press release issued after the meeting. Many of the board’s findings align with positions the rail industry has long maintained, such as the need to phase out DOT-111 tank cars from hazmat service.
The rail industry’s interchange standards allow freight railroads to put safety lessons learned into practice faster than regulators can mandate new rules, AAR officials said.
“Rail remains one of the most regulated industries in the nation — and still freight railroads continue to implement standards often exceeding federal requirements,” AAR officials stated. “At the same time, federal regulators often incorporate AAR standards within the regulations by reference in recognition of the industry’s long track record for advancing safety-centered expertise in establishing operating practices.”
Some Congress members also issued comments following the NTSB’s meeting. U.S. Sen. Maria Cantwell (D-Wash.), chair of the Senate Committee on Commerce, Science and Transportation, renewed her calls for Congress to pass the proposed Railway Safety Act of 2023, which passed the committee in May 2023.
“Railroads have been treating derailments as the cost of doing business – each incident poses a risk to communities, train crews, first responders and the environment, said Cantwell in a press release. “The Railway Safety Act takes key steps to address both the East Palestine derailment and the 1,285 other derailments that happened last year alone. ... Congress must act to strengthen safety oversight, require the use of advanced safety technologies, and improve emergency preparedness on our railways.”
U.S. Sen. Sherrod Brown (D-Ohio), who along with Sen. J.D. Vance (R-Ohio) introduced the Railway Safety Act, called for rail reform after the NTSB approved its East Palestine report. The bill calls new rail safety protocols, such as procedures for trains carrying hazardous materials, establishing requirements for wayside defect detectors, creating a permanent requirement for railroads to operate with at least two-person crews, and increasing fines for wrongdoing committed by rail carriers.
“The NTSB made crystal clear what we have been saying for over a year – stronger rail safety regulations are needed immediately,” Brown said in a press release. “Congress needs to pass the Railway Safety Act to enact stronger safety rules and hold the big railroad companies accountable.”
The NTSB report confirms that Congress must pass legislation to protect rail workers and communities, and to hold railroads accountable, said House Transportation and Infrastructure Committee Ranking Member Rick Larsen (D-Wash.) in a press release.
“It’s time for the T&I Committee to move forward on rail safety legislation in a bipartisan way, and I look forward to doing just that,” Larsen said.
