NTSB issues new safety actions to avert another East Palestine

The National Transportation Safety Board (NTSB) said Tuesday that a rail car’s defective wheel bearing caused the train derailment and subsequent hazardous material release in East Palestine, Ohio, last year.

NTSB investigators said that the derailment occurred when a bearing on a hopper car failed and overheated, leading to the fiery derailment of a Norfolk Southern Railway train. At a meeting held at East Palestine High School, the NTSB discussed its investigators’ 37 findings in the case that began the night of Feb. 3, 2023, when 38 rail cars on the train derailed, causing a fire and later leading to a decision to conduct a vent and burn involving toxic chemicals in five of the train’s tank cars.

In presenting their findings, NTSB investigators said the decision by the local incident commander three days later to conduct a vent and burn of the contents of the tank cars carrying vinyl chloride monomer was based on incomplete and misleading information provided by NS officials and contractors. The vent and burn was not necessary to prevent a tank car failure, NTSB investigators found.

The board issued 25 safety improvement recommendations directed at several organizations, including NS, the Association of American Railroads (AAR), Federal Railroad Administration, Pipelines Hazardous Materials Safety Administration, the state of Ohio, the International Association of Fire Chiefs, the International Association of Fire Fighters, the National Volunteer Fire Council and The Chlorine Institute. 

In addition, four previously issued and reiterated recommendations were directed at the U.S. Department of Transportation secretary, the FRA and the Class Is.

The board 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. The conclusion resulted in the vent and burn of the five cars, which led to the release of toxic chemicals and a giant plume of dark smoke that hovered ominously over the area.

The controlled burn required a community evacuation and prompted East Palestine residents to be concerned about long-term health impacts of the release of those toxic chemicals. 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 vent-and-burn 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.

Contributing to the severity of the hazardous materials release was the continued use of DOT-111 tank cars to transport flammable liquids and other hazardous materials. During the derailment, three DOT-111 cars were mechanically breached, releasing flammable and combustible liquids that ignited, investigators said.

The DOT-111 tank car is being phased out of flammable-liquids service because of its long record of inadequate mechanical and thermal crashworthiness and propensity to release lading in a derailment, NTSB officials said.  The board has called for an accelerated phaseout of DOT-111 tank cars in hazmat service.

Overheated wheel bearings are a common cause of rail accidents, according to NTSB officials. Hot-bearing detectors are part of a system intended to warn crews to stop the train before the hot bearing can cause a derailment. In the East Palestine case, the train crew did not receive a hot-bearing warning until the train passed over a detector in East Palestine, when the overheated bearing was about to cause its axle to fail. The crew began to slow the train using dynamic braking, but it was too late.

Additional coverage of yesterday's board meeting and conclusions, as well as responses from NS, AAR and others, will be covered tomorrow in Progressive Railroading's RailPrime online subscription news service.