EAST PALESTINE, Ohio – Norfolk Southern and its contractors should not have decided to vent and burn derailed tank cars carrying vinyl chloride three days after the Feb. 3, 2023, derailment in East Palestine, the National Transportation Safety Board said today (Tuesday, June 25).
The five tank cars were among the 38 cars of train 32N that derailed after the catastrophic failure of a wheel bearing on a covered hopper. The bearing was on fire but did not trigger critical alarms at two hot bearing detectors the train passed before reaching East Palestine, where the wayside detector alert sounded just moments before the fiery wreck.
The probable cause of the derailment, the NTSB concluded, was the failure of the wheel bearing on the hopper, the 23rd car in the 149-car consist. The derailment led to a fire that likely began with the release of a flammable liquid from a DOT-111 tank car that was punctured during the wreck. It left a 1,100-foot trail of butyl acrylates along the track.
The NTSB identified two factors that contributed to the severity of the hazardous materials release. The first was the continued use of DOT-111 tank cars in hazmat service, despite years of concern over their design and their tendency to breach during derailments. The second was the decision to vent and burn five vinyl chloride monomer tank cars. NS and its contractors provided incomplete and inaccurate information to the incident commander, which the board said created an “unwarranted sense of urgency and incorrectly represented the tank cars as at risk of failure from a polymerization reaction.”
NS feared the potential chain chemical reaction would have led to an explosion that would have sent hazardous materials and shrapnel through the town on the Ohio-Pennsylvania border. But the NTSB’s investigation found no evidence that a polymerization reaction was under way in any of the tank cars, that NS and its contractors ignored evidence that suggested the threat was diminishing, and that the vent and burn operation was not necessary.
The board also said that NS’s delay in transmitting train consist data to emergency responders, along with Ohio’s insufficient training standards for volunteer firefighters, contributed to “unnecessary and increased” public and first responder exposure to hazardous materials.
Norfolk Southern was critical of the NTSB’s characterization of the vent and burn decision.
“Norfolk Southern and its expert contractors’ only motivation in recommending the vent and burn to the Unified Command was the health and safety of the community and first responders,” the railroad said. “After carefully considering all alternatives, Norfolk Southern and its specialist contractors recommended a controlled vent and burn to the Unified Command as the only option to protect the community from a potential catastrophic explosion. This recommendation was developed under guidance from two of only three specialized firms in the country certified by the Chlorine Institute to respond to vinyl chloride emergencies.”
NS also said that NTSB “mischaracterized the basis of the recommendation as being solely predicated on polymerization. That is not accurate. Several key factors indicated the strong possibility of a catastrophic, uncontrolled explosion.”
NTSB Chair Jennifer Homendy called the railroad’s statement “insulting” and said that the East Palestine fire chief and deputy chief did a phenomenal job with the information and resources that were available. The problem, she said, is that they didn’t have all the information they needed.
The NTSB made 31 new recommendations, along with updates to five previously issued recommendations. The safety recommendations cover improving the detection of wheel bearing failures, providing first responders with necessary training and hazardous materials information, implementing tougher tank car standards, and tightening operational restrictions on trains carrying hazardous materials.
The NTSB also urged improving communication among railroads, derailment contractors, chemical manufacturers, and first responders before a last-resort decision is made to vent and burn tank cars laden with flammable hazardous materials.
The decision to vent and burn in East Palestine, the board said, was hampered by poor communication, confusing and misleading information, and a disregard for evidence that did not support releasing and igniting the contents of the tank cars.
“The decision-making process here was very much flawed,” Board member Thomas Chapman said.
The NTSB recommendations included those aimed at railroads in general and NS in particular, as well as regulators, shippers, chemical manufacturers, and first responders.
The board asked the Federal Railroad Administration to research hot bearing detectors and use the data to establish minimum requirements for hotbox temperature and alarm thresholds, the spacing of wayside detectors, and their installation and maintenance. Wayside detectors are not currently regulated, and railroads have pledged to reduce spacing to an average of 15 miles.
“A hot bearing detector traversed by train 32N detected an elevated temperature on the overheating bearing, but the low priority alert it transmitted to railroad personnel did not reflect the true condition of the failing bearing. Because of design constraints, hot bearing detectors are likely to indicate misleadingly low bearing temperatures. This limit on detector performance, combined with NS’s standard operating procedures and the spacing between detectors, meant that the train’s crew did not have adequate warning to stop the train before the derailment,” the NTSB said.
The NTSB also recommended that the Association of American Railroads create a database of bearing failure and replacement data to help regulators and the industry identify and address bearing failure risks. Wheel bearing failures cause an average of 17 main line derailments per year.
The board urged an accelerated phase-out of DOT-111 tank cars that carry hazardous materials. The current deadline is May 2029, but the board said it was feasible for shippers to move more quickly despite disincentives to do so.
Board member Michael Graham said the use of DOT-111 tank cars in hazardous materials service exposes communities to unnecessary continued risk.
“The post-derailment fires likely began because of hazardous materials released from a punctured DOT-111 tank car. The subsequent release of VCM from mechanically intact DOT-105 tank cars likely would not have occurred if the DOT-111 tank cars in the consist had survived the derailment,” the board said.
The board made several recommendations to the Pipeline and Hazardous Materials Shipping Administration. Among them: broaden the type of trains that can be considered high-hazard flammable trains; obtain legislative authority to accelerate the deadline for phasing out DOT-111 tank cars; and require that hazmat placards can remain legible and survive derailments and fires.
Norfolk Southern should review and revise policies to ensure accurate train consist information is immediately available to first responder and address policies for contractors to keep detailed records and share information used to make emergency response decisions, the board said.
Chemical manufacturers and shippers should ensure that their expertise is communicated to and shared with incident command at hazmat wrecks, the NTSB said. OxyVinyls, the manufacturer of the vinyl chloride in the cars that were vented and burned, also was asked to update its data sheet to accurately reflect risks of vinyl chloride monomer.
The final NTSB report, which will include revisions from the hearing, will be available online in a few weeks. The board’s synopsis of today’s meeting is available online.
Note: This story, posted at 8:37 p.m. CT, replaces an earlier version that was posted before the NTSB voted on the recommendations made by its staff of investigators.
NTSB makes recommendations and does not issue regulations, that is Mayo Pete’s department under the guidance of Amtrak Joe. Of course the “Rail Safety Act of 2023” is dead in the water. The Association of American Railroads lobbyists and lawyers did an excellent job!
The “OHIO should” paragraph should be for all states, it seems to be a pretty good recommendation.
Hindsight is always 20/20. And unlike Waverly TN nobody got killed and East Palestine is still standing.
At the time, recall NS did not encourage venting the cars but ceded final call to the local fire commander who then made the decision to vent. Open for correction. Be gentle, please.
I believe you are correct. I remember seeing that somewhere also.
Two items that stood out for me were “disregard for evidence that showed an explosive polymerization reaction was not going on inside one of the derailed tank cars” and “correct an incident report to reflect information…”