Paulsboro, New Jersey
November 30, 2012
NTSB Number: RAR-14-01
NTIS Number: PB2014-108828
Adopted: July 29, 2014
On Friday, November 30, 2012, at 6:52 a.m. eastern standard time, southbound Consolidated Rail Corporation freight train FC4230, arrived and stopped on the main track at the Paulsboro moveable bridge near milepost 13.7 on the Consolidated Rail Corporation Penns Grove Secondary Subdivision in Paulsboro, New Jersey. A red signal aspect was displayed and did not change to green when the radio signal command was executed by the train crew, indicating that the bridge was not prepared for train movement. One of two conditions were required before the train could safety begin movement over the bridge: (1) Signal aspect changed to green, indicating that the running rails were aligned and locked to the fixed track and both ends of the bridge, or (2) The bridge was visually inspected by a qualified employee to ascertain that the running rails were aligned and locked to the fixed track at both ends of the bridge and permission was granted by the train dispatcher for the train to pass the red signal.
Despite multiple attempts by the train crew to remotely execute a radio signal command to align and lock the bridge, the signal aspect remained red and did not turn green. The conductor inspected the bridge and erroneously concluded it was properly locked to prevent movement. The engineer informed the dispatcher of the conductor's findings. The dispatcher then gave permission for the train to pass the red signal aspect and cross the bridge, as allowed by Consolidated Rail Corporation operating rules and procedures.
About 7:02 a.m., as the train traveled over the bridge, 7 cars derailed, the 6th through the 12th cars. Physical evidence indicated that the swing span locking mechanism was not engaged at the east end of the bridge. The bridge span rotated under the moving train, misaligned the running rails, and caused the train to derail. The bridge was structurally sound and did not collapse. Four tank cars that derailed on the bridge came to rest partially in Mantua Creek. Three of the derailed tank cars that entered the creek contained vinyl chloride and one contained ethanol. One tank car was breached and released about 20,000 gallons of vinyl chloride. Eyewitnesses reported a vapor cloud engulfed the scene immediately following the accident.
On the day of the accident, 28 area residents sought medical attention for possible vinyl chloride exposure. The train crew and numerous emergency responders were also exposed to vinyl chloride.
Equipment damage estimates were $451,000. The emergency response and remediation costs totaled about $30 million.
The National Transportation Safety Board determines that the probable cause of the derailment and subsequent hazardous material release at the Paulsboro moveable bridge was Consolidated Rail Corporation (1) allowing the train to proceed past the red signal aspect with the rail slide locks not fully engaged, which allowed the bridge to rotate and misalign the running rails as the train moved across it, and, (2) relying on a training and qualification program that did not prepare the train crew to examine the bridge lock system.
Contributing to the accident was the lack of a comprehensive safety management program that would have identified and mitigated the risks associated with the continued operation of the bridge despite multiple bridge malfunctions of increasing frequency.
Contributing to the consequences of the accident was the failure of the incident commander to implement established hazardous materials response protocols for worker protection and community exposure to the vinyl chloride release.
As a result of this investigation, the National Transportation Safety Board makes safety recommendations to the US Department of Transportation, the Federal Railroad Administration, the Pipeline and Hazardous Materials Safety Administration, Consolidated Rail Corporation, the Association of American Railroads, the American Short Line and Regional Railroad Association, the International Association of Fire Chiefs, the National Volunteer Fire Council, the New Jersey State Police Office of Emergency Management, the New Jersey Bureau of Fire Department Services, the New Jersey Department of Labor and Workforce Development, and the New Jersey Department of Health. The National Transportation Safety Board also reiterates recommendations to the Federal Railroad Administration and the Pipeline and Hazardous Materials Safety Administration.