NTSB Releases East Palestine Summary; AAR, NS Respond (Updated June 26)

National Transportation Safety Board Chair Jennifer Homendy at the Jan. 25 public meeting in East Palestine, Ohio. Screenshot of the meeting video.

The National Transportation Safety Board (NTSB) on June 25 held a public meeting in East Palestine, Ohio, site of the Feb. 3, 2023 derailment of a Norfolk Southern freight train that resulted in a hazmat release and fires. NTSB’s five-member board, led by Chair Jennifer Homendy, heard presentations from investigators, deliberated over its draft final report, and voted on the proposed findings, probable cause, safety recommendations and amendments to that draft. NTSB said it will publish a final report within “several weeks” but did not provide timeline details. A synopsis of the investigation, Norfolk Southern Railway Train Derailment with Subsequent Hazardous Material Release and Fires, can be downloaded below. The Association of American Railroads and Norfolk Southern immediately issued respectful but firm statements as the NTSB meeting concluded.

At the meeting, NTSB confirmed its preliminary findings that a wheel bearing burn-off caused the derailment, and that wayside HBDs (hot bearing detectors) failed to accurately measure the faulty bearing’s temperature. NTSB also said that Norfolk Southern and its contractors were incorrect in deciding to vent five tank cars and burn the vinyl chloride they were carrying. The NTSB approved 37 findings, issued 31 new recommendations, reiterated one previously issued recommendation, and classified four previously issued recommendations. 

The synopsis from the NTSB’s report “does not include the Board’s rationale for the findings, probable cause, and safety recommendations,” the agency said. “NTSB staff is currently making final revisions to the report from which the attached findings and safety recommendations have been extracted. The final report and pertinent safety recommendation letters will be distributed to recommendation recipients as soon as possible. The attached information is subject to further review and editing to reflect changes adopted during the Board meeting.”

The 37 findings:

1. “None of these issues contributed to the derailment of train 32N and subsequent hazardous materials release: (1) defects in railroad track or infrastructure; (2) the signals or train control system; (3) the train crew’s proper train handling and appropriate response to the bearing alarm and derailment; (4) the marking, placarding, and method of loading for the derailed vinyl chloride monomer tank cars; (5) the weight and lading volume of the derailed hazardous materials tank cars; and (6) the mechanical crashworthiness of the derailed DOT-105 tank cars.
2. “Train 32N derailed because the L1 bearing on railcar GPLX75465 overheated and caused the axle to separate, causing the railcar’s lead truck to derail.
3. “There is insufficient evidence to determine if the Terminal Railroad Association of St. Louis mechanical inspection of train 32N on February 1, 2023, failed to identify signs of failure on hopper car GPLX75465’s L1 wheel bearing.
4. “The non-critical alert transmitted by the Salem, Ohio, hot bearing detector did not reflect the true temperature and failing condition of the L1 wheel bearing.
5. “A failing wheel bearing’s actual internal temperatures will likely exceed external temperatures measured and reported by a hot bearing detector (HBD), and this limit on HBD accuracy is inherent in how current HBDs and railcar trucks are designed.
6. “The combination of Norfolk Southern Railway standard operating procedures that required only continued monitoring for non-critical bearing alerts, the limited ability of hot bearing detectors to measure a bearing’s actual internal temperature, and the distance between detectors did not give the train’s crew adequate warning to stop the train before the suspect bearing failed and caused the derailment.
7. “Without research into how differences in alert and alarm thresholds and varied distances between detectors affect the performance of wayside bearing defect detection systems, railroads and regulators lack the information to determine what changes would produce significant safety improvements.
8. “Regulatory requirements for the installation, inspection, and maintenance of wayside bearing defect detectors would protect the reliability of these devices and improve the safety of railroad operations.
9. “Because the effectiveness of wayside bearing defect detection systems depends on appropriate operational responses, and because the rail industry has yet to arrive at a consensus standard for these responses, research is necessary to determine what operational responses to bearing alerts and alarms are sufficient to prevent bearing-related accidents.
10. “A database capturing bearing failure and replacement information could help identify what factors pose an increased risk of burn-off so that railroads, regulators, and investigators can better address bearing-related safety issues.
11. “While the East Palestine Fire Department deputy fire chief and other volunteer firefighters acted in good faith to protect their community, the initial emergency response did not conform to Emergency Response Guidebook guidance for fires involving tank cars and unknown materials; both the proximity of the first command post to the fire and the use of manned hoses near a fire involving unknown materials placed these firefighters at unnecessary risk.
12. “The state of Ohio’s statutory requirements for volunteer firefighter training were insufficient to support a safe emergency response to the East Palestine derailment led by a volunteer fire department.
13. “Because there were not common radio channels between all responding agencies, the emergency response lacked efficient coordination.
14. “The delayed transmittal of consist information by Norfolk Southern Railway to emergency responders needlessly increased the time emergency responders spent near the derailment pileup and delayed the evacuation order, resulting in unnecessary and increased exposure of emergency responders and the public to postderailment hazards.
15. “The Pipeline and Hazardous Materials Safety Administration’s Hazardous Materials: FAST Act Requirements for Real-Time Train Consist Information addresses the safety concerns of Safety Recommendation R-07-4.
16. “The vulnerability of tank car placards to fire exposure resulted in illegible placards and hampered emergency responders’ efforts to identify hazards.
17. “The postderailment fire likely began with hazardous material released from a mechanically breached DOT-111 tank car, most probably the butyl acrylates released from tank car UTLX205907.
18. “If DOT-111 tank cars transporting combustible and flammable liquids had not sustained mechanical breaches during the derailment, the DOT-105 tank cars transporting vinyl chloride monomer likely would not have been exposed to the fire conditions that led to concerns about polymerization and ultimately the vent and burn actions that released additional lading from those five DOT-105 tank cars.
19. “Voluntary industry action to improve the safety of the tank car fleet by completing the phase out of remaining DOT-111 tank cars in flammable liquids service ahead of the Fixing America’s Surface Transportation Act mandate is feasible, but such action is unlikely because of economic and business disincentives.
20. “The presence of DOT-111 tank cars carrying hazardous materials in a mixed freight train increases the risk of lading releases from other, more resilient tank cars during a derailment.
21. “The current Association of American Railroads tank car certificate of construction approval process lacks a means of verifying manufacturers’ claims and is therefore insufficient to ensure that tank cars and their fittings are appropriate for their specified lading.
22. “While the use of aluminum in the vinyl chloride monomer tank cars and pressure relief devices rendered them susceptible to thermal damage, there is insufficient evidence to determine whether this greater susceptibility created a safety hazard or contributed to the release of hazardous materials following the East Palestine derailment.
23. “Cascading hazardous materials releases are not unique to high-hazard flammable trains, and the probability of a cascading hazardous materials release depends in part on variations in tank car survivability and on the presence of hazardous materials other than Class 3 flammable liquids, such as combustible liquids and Division 2.1 flammable gases.
24. “The definition of key train in Association of American Railroads Circular OT-55 does not account for differences in survivability between different tank car specifications, and the DOT-111 and AAR-211 specifications can pose an elevated risk of a hazardous materials release compared to other specifications, such as the DOT-117.
25. “Post-accident examinations, which found no solidified chemical matter blocking pressure relief devices and other tank car service equipment openings, do not indicate that a polymerization reaction occurred within any of the five vinyl chloride monomer tank cars.
26. “The observed downward temperature trend in tank car OCPX80370 indicates that polymerization was not occurring within the tank car, contrary to the representation by Norfolk Southern Railway and its contractors.
27. “The vinyl chloride monomer within the derailed DOT-105 tank cars remained in a stabilized environment until the vent and burn and did not undergo polymerization; the vent and burn procedure was not necessary to prevent a polymerization-induced tank rupture.
28. “Language in The Chlorine Institute’s Pamphlet 171 overstates the probability of vinyl chloride monomer polymerization in scenarios where tank cars remain intact, likely leading those using the pamphlet during an emergency response effort to overestimate the likelihood of polymerization.
29. “Because Level 3 CHLOREP contractors are expected to provide advanced emergency response capabilities, including communicating expertise to other on-scene personnel and the transloading of vinyl chloride monomer (VCM), these contractors should possess or know how to obtain enough technical knowledge to accurately assess how chemical hazards, such as polymerization, affect a safe response to a VCM incident.
30. “Information collected during real-world accidents is a vital resource in ensuring that hazardous materials guidance is suitable for supporting responses to transportation emergencies.
31. “Norfolk Southern Railway and its contractors continued to assert the necessity of a vent and burn after expert opinion and available evidence should have led them to re-evaluate their initial conclusions regarding polymerization.
32. “Norfolk Southern Railway and its contractors compromised the integrity of the vent and burn decision by creating unwarranted urgency and not communicating expert opinions and information completely and accurately to the incident commander.
33. “The absence of Oxy Vinyls’ expertise from the formal incident command denied the incident commander relevant information necessary to make a fully informed decision about the vent and burn.
34. “No explanation or argument for Norfolk Southern Railway and its contractors’ continued advocacy for the vent and burn procedure justifies failing to communicate relevant expertise and dissenting opinions to the incident commander.
35. “The significant local and environmental impacts of a vent and burn decision demonstrate the need for federal guidance about what products and circumstances are candidates for the vent and burn method.
36. “Inward- and outward-facing recorders can improve the quality of accident and incident investigations and provide the opportunity for proactive steps by railroad management to verify that train crew actions are in accordance with safety rules and procedures.
37. “The Federal Railroad Administration’s final rule in response to the Fixing America’s Surface Transportation Act did not require audio recording in passenger locomotives and did not require inward- and outward-facing image and audio recording in freight rail locomotives, resulting in a missed opportunity to record important safety data.”

DOWNLOAD NTSB SYNOPSIS

AAR Responds

“NTSB investigators have spent more than a year analyzing the derailment’s causes to inform recommendations aimed at preventing similar accidents,” said Association of American Railroads Senior Vice President Safety and Operations Michael Rush. “Railroads implemented substantial, industry-wide improvements in response to the NTSB’s initial findings. With the final report, railroads will carefully evaluate key learnings and determine next steps to meaningfully advance safety.” 

“Among the recommendations, many of the NTSB findings align with positions the industry has long maintained, including the need to aggressively phase out DOT-111 tank cars from hazmat service and other tank car improvements,” AAR said. “Following today’s hearing, railroads are reviewing the complete findings and recommendations to identify the potential need for additional research surrounding bearing performance or other joint industry efforts.  

“The rail industry’s interchange standards allow freight railroads to more rapidly implement learnings that enhance safety than safety regulators can initiate and finalize rulemaking procedures. An example of this is the long-standing, industry-wide work to enhance tank car design standards. Rail remains one of the most regulated industries in the nation — and still freight railroads continue to implement standards often exceeding federal requirements. 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.  

“Since the NTSB released its preliminary findings, railroads have applied lessons learned and taken significant steps that bolster safety and address what happened in the February 2023 incident. This includes a multi-prong approach to enhance the effectiveness of wayside detectors, improve first-responder preparedness and address tank car standards. These new steps complement the more than $23 billion railroads invest annually in rail safety, employee training, infrastructure improvements and technological advancements. 

“Starting decades ago, railroads voluntarily developed, and have since widely deployed, wayside detectors to help prevent accidents caused by overheated bearings. The data clearly demonstrates these detectors have enhanced safety. Since East Palestine, railroads have taken three key steps that work in concert to further enhance the effectiveness of these detectors including: 

• “Increased the frequency of hot bearing detectors (HBDs) across key routes. 
• “Established a new industry standard of stopping and inspecting trains when an HBD reading exceeds 170° F. Effective July 1, 2023, AAR rules lowered the temperature threshold from 200° F to 170° F. 
• “Reviewed carriers’ current trending analysis programs to develop uniform recommendations for proactively identifying bearings that may become problematic. On November 29, 2023, railroads established a new, industry-wide trending analysis rule, informed by Railinc’s comprehensive analysis of 150 algorithms used by the Class I carriers to pinpoint the most effective algorithm for detecting problematic bearings. Railinc is the industry’s leading technology and data solutions partner. 

“Ensuring first responders are properly trained to respond safely in the event of an incident, and can access the information they need should an incident occur, are top priorities for the rail industry. Since February 2023, railroads have redoubled these efforts through: 

• ”Dramatically expanding access to AskRail, which provides real-time information on rail car contents and the safe handling of those materials. Today, AskRail information is now available to more than 2.3 million first responders across the U.S. and Canada through our work with both CHEMTREC and CANUTEC, emergency call centers for hazmat handling as well as with dispatchers in Emergency Communications Centers (ECCs). Railroads continue outreach and onboarding for ECCs across the nation with 224 fully onboarded and another 55 currently in the onboarding process. “Dramatically expanding access to AskRail, which provides real-time information on rail car contents and the safe handling of those materials. Today, AskRail information is now available to more than 2.3 million first responders across the U.S. and Canada through our work with both CHEMTREC and CANUTEC, emergency call centers for hazmat handling as well as with dispatchers in Emergency Communications Centers (ECCs). Railroads continue outreach and onboarding for ECCs across the nation with 224 fully onboarded and another 55 currently in the onboarding process. 
• “This year, Class I railroads have trained more than 16,000 first responders, and more than 1,000 have received specialized training at the industry’s Security and Emergency Response Training Center (SERTC). In 2023, Class I railroads trained about 35,500 first responders and provided specialized training at SERTC to 1,800 responders. 

“Based upon the public hearing last year, it is likely the NTSB will also call for enhancements to tank car standards, something railroads have strongly supported for decades. Since the incident, railroads have identified ways to improve the fire performance of tank cars and other service equipment. AAR’s Tank Car Committee (TCC) is working to enhance standards related to bottom valve protection to increase safety. This is a voluntary joint initiative between the industry and the hazmat shippers who own the tank cars.” 

NS Responds

“We appreciate the NTSB’s investigation, recommendations for enhancing rail safety, and the acknowledgement of the steps we’ve taken to improve safety,” Norfolk Southern said in a statement. “Over the past 16 months we have implemented many enhancements and technologies to make our railroad even safer, and have achieved meaningful results.”

“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 NTSB recommendations specific to Norfolk Southern, we have taken action to enable the immediate availability of train consist information to first responders and encourage contractors to share information to make emergency response decisions,” NS said. “In addition, we have substantially addressed the Federal Railroad Administration (FRA) recommendations from its 2023 Safety Culture Assessment. As a result of these actions and others, our main line accident rate declined 38% last year to industry leading levels. We will move quickly to compare the NTSB’s recommendations to our current protocols and will implement those that advance our safety culture. 

“The NTSB again confirmed our crew’s actions reflect the professionalism and commitment to safety of all Norfolk Southern operators. Specifically, investigators noted:

• “The rail crew operated the train below the track speed limit and handled the train in an approved manner.
• “There were no track defects.
• “Once the rail crew was alerted by the wayside detector, they acted appropriately by immediately beginning to stop the train.”

NS added that it has:

• “Become the first railroad to partner with RapidSOS, a digital platform that connects the devices of more than 16,000 emergency response agencies to immediately provide first responders with real-time access to train consists, train locations, and emergency response protocols.
• “Continued to advocate for phasing out inferior customer-owned DOT-111 tank cars and imposing a more expedited phaseout timetable than federal regulations have provided given our role as a common carrier under which we are obligated to accept DOT-111 tank cars.
• “Launched and implemented Six-Point Safety Plan including installing 187 additional HBDs, reducing core network average distance between detectors to approximately 12 miles; quadrupling acoustic bearing detectors; developing and deploying Digital Train Inspection Portals, using ultra-high-resolution cameras and machine vision; and investing in next-generation inspection technology.
• “Continued to invest significant resources in training first responders on hazmat response.
• “Broke ground on a new regional first responder training center in East Palestine, Ohio and will invest $25 million in the new center.
• “Continued to provide classroom and online resources, tabletop drills, and full-scale exercises to help responders prepare for incidents through our OAR program.
• “Participated in industry efforts to help communities develop emergency response plans.
• “In collaboration with labor unions, become the first Class I railroad to join the FRA’s Confidential Close Call Reporting System.
• “Brought in world-class safety experts, AtkinsRéalis (ANS) to conduct an independent review and implement a 2-3 year roadmap of additional safety initiatives.”

Regarding the vent and burn recommendation, NS said that it “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. 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.

“Several key factors indicated the strong possibility of a catastrophic, uncontrolled explosion including:

• “The tank cars had been damaged in a high-speed derailment and were exposed to extensive pool fires.
• “The pressure relief devices were not working – the behavior of the pressure relief devices on the affected tank cars indicated that dangerous pressure was building inside the tank cars without being properly released.
• “The manufacturer’s safety guidance warned that vinyl chloride monomer may polymerize when exposed to the conditions present at the derailment.
• “Other options for safely removing the vinyl chloride monomer cars from the derailment site (such as rerailing them) were not possible, due to damage sustained in the derailment and dangerous conditions on-site.

“Norfolk Southern and its contractors received conflicting information from Oxy Vinyls’ personnel as to whether polymerization was or could be occurring. And Oxy Vinyls’ safety data sheet was clear that polymerization was possible in the circumstances observed at the derailment.  Norfolk Southern does not agree with the conclusion that it ‘withheld’ Oxy Vinyls’ views from the Unified Command. Oxy Vinyls had every opportunity to participate in the Unified Command. They were on scene in the building where the Unified Command was operating. There was no obstacle to Oxy Vinyls making their views known to the ultimate decision-makers. Unified Command was advised that a vent and burn procedure might be necessary approximately 20 hours before the Unified Command made the final decision to proceed with the operation. Expert contractors began necessary preparations in the event a vent and burn recommendation was adopted. The vent and burn effectively avoided a potential uncontrolled explosion. There was no loss of life and contractors took steps to manage environmental impact. 

“Norfolk Southern will convene a Vent and Burn Workgroup to integrate key learnings for any future scenario where a vent and burn may be necessary.  The Workgroup is being developed pursuant to the Company’s DOJ/EPA Consent Decree, which is currently awaiting court approval. Norfolk Southern supports and looks forward to helping improve Unified Command processes, including through the Vent and Burn Workgroup. We believe it should be a requirement for stakeholders to directly voice their concerns to Unified Command.

“We promised to clean the site safely, thoroughly and with urgency—and we’re a company that keeps its promises. We have made significant progress with respect to environmental remediation and completed the removal of impacted soil. Robust sampling programs, under EPA oversight, at the derailment site and in the community at large have consistently shown the air and water around the site are safe. We have also invested more than $5 million to overhaul the municipal water system with state-of-the-art technology including new engineering and carbon filtration systems. 

“We take our responsibility to East Palestine and the surrounding community seriously. Since day one we have followed through on our commitment to doing what’s right to ensure the area recovers and thrives. We continue to update our progress at NSMakingItRight.com.”