Railroad Accident Report

Derailment of Canadian Pacific Railway Freight Train 292-16 and Subsequent Release of Anhydrous Ammonia

Minot, North Dakota
January 18, 2002

NTSB Number: RAR-04-01
NTIS Number: PB2004-916301
Adopted March 9, 2004
PDF

Executive Summary:

At approximately 1:37 a.m. on January 18, 2002, eastbound Canadian Pacific Railway freight train 292-16, traveling about 41 mph, derailed 31 of its 112 cars about 1/2 mile west of the city limits of Minot, North Dakota. Five tank cars carrying anhydrous ammonia, a liquefied compressed gas, catastrophically ruptured, and a vapor plume covered the derailment site and surrounding area. The conductor and engineer were taken to the hospital for observation after they complained of breathing difficulties. About 11,600 people occupied the area affected by the vapor plume. One resident was fatally injured, and 60 to 65 residents of the neighborhood nearest the derailment site were rescued. As a result of the accident, 11 people sustained serious injuries, and 322 people, including the 2 train crewmembers, sustained minor injuries. Damages exceeded $2 million, and more than $8 million has been spent for environmental remediation.

Probable Cause

The National Transportation Safety Board determines that the probable cause of the derailment of Canadian Pacific Railway train 292-16 was an ineffective Canadian Pacific Railway inspection and maintenance program that did not identify and replace cracked joint bars before they completely fractured and led to the breaking of the rail at the joint. Contributing to the severity of the accident was the catastrophic failure of five tank cars and the instantaneous release of about 146,700 gallons of anhydrous ammonia.

The safety issues identified in this accident were as follows:

The analysis also addresses the appropriateness of using shelter-in-place to protect the public from the release of hazardous material.

Recommendations

As a result of its investigation of the January 18, 2002, freight train derailment near Minot, North Dakota, the National Transportation Safety Board makes the following safety recommendations:

To the Federal Railroad Administration:

Require all railroads with continuous welded rail track to include procedures (in the programs that are filed with the Federal Railroad Administration) that prescribe on-the-ground visual inspections and nondestructive testing techniques for identifying cracks in rail joint bars before they grow to critical size. (R-04-1)

Establish a program to periodically review continuous welded rail joint bar inspection data from railroads and Federal Railroad Administration track inspectors and, when determined necessary, require railroads to increase the frequency or improve the methods of inspection of joint bars in continuous welded rail. (R-04-2)

Instruct Federal Railroad Administration track inspectors to obtain copies of the most recent continuous welded rail programs of the railroads that fall within the inspectors' areas of responsibility and require that inspectors use those programs when conducting track inspections. (R-04-3)

Conduct a comprehensive analysis to determine the impact resistance of the steels in the shells of pressure tank cars constructed before 1989. At a minimum, the safety analysis should include the results of dynamic fracture toughness tests and/or the results of nondestructive testing techniques that provide information on material ductility and fracture toughness. The data should come from samples of steel from the tank shells from original manufacturing or from a statistically representative sampling of the shells of the pre-1989 pressure tank car fleet. (R-04-4)

Based on the results of the Federal Railroad Administration's comprehensive analysis to determine the impact resistance of the steels in the shells of pressure tank cars constructed before 1989, as addressed in Safety Recommendation R-04-4, establish a program to rank those cars according to their risk of catastrophic fracture and separation and implement measures to eliminate or mitigate this risk. This ranking should take into consideration operating temperatures, pressures, and maximum train speeds. (R-04-5)

Validate the predictive model the Federal Railroad Administration is developing to quantify the maximum dynamic forces acting on railroad tank cars under accident conditions. (R-04-6)

Develop and implement tank car design-specific fracture toughness standards, such as a minimum average Charpy value, for steels and other materials of construction for pressure tank cars used for the transportation of U.S. Department of Transportation class 2 hazardous materials, including those in low-temperature service. The performance criteria must apply to the material orientation with the minimum impact resistance and take into account the entire range of operating temperatures of the tank car. (R-04-7)

To the Canadian Pacific Railway:

Finalize and submit to the Federal Railroad Administration your revised continuous welded rail maintenance program and ensure that all maintenance employees are trained in the requirements of the new program. (R-04-8)