Railroad Accident Report:
Conrail Freight Train Derailment with Vinyl Chloride Release

This is a synopsis from the NTSB's report and does not include the Board's rationale for the conclusions, probable cause, and safety recommendations. NTSB staff is currently making final revisions to the report from which the attached conclusions 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.

EXECUTIVE SUMMARY

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 safely 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 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.

This report addresses the following safety issues:

  • Training and qualification of train crews for moveable bridge inspection
  • Consolidated Rail Corporation safety management
  • Timeliness of hazardous materials communications to first responders
  • Failure of the incident commanders to follow established hazardous materials response protocols
  • Firefighter training and qualifications
  • Inadequacies of emergency planning, emergency preparedness, and public awareness for hazardous materials transported by train
  • Rail corridor risk management analysis

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.

CONCLUSIONS

1. The following were not contributing factors to the accident:

  • Weather
  • Alcohol or illicit drugs
  • Train equipment
  • Track
  • Structural integrity and bridge load
  • Bridge control system
  • Bridge signal system

2. The recorded data and postaccident physical condition of the slide lock components indicate that the slide locks were not engaged on the east end of the bridge and the slide locks on the west end were only partially engaged as the train crossed the bridge.

3. Physical evidence shows that the east end of the bridge span rotated north under the moving train, misaligned the running rails, and caused the train to derail.

4. The conductor erroneously determined the Paulsboro moveable bridge locking mechanism was locked.

5. Consolidated Rail Corporation failed to ensure that inspections of the Paulsboro moveable bridge locking mechanisms would be conducted by properly qualified employees.

6. The requirements for ensuring that an employee is qualified to determine if a train can safely proceed across a moveable bridge when a red signal aspect is displayed are not as comprehensive as the requirements for other safety-critical operations such as operating a train over a broken rail.

7. Consolidated Rail Corporation's reliance on unstructured on-the-job training to determine whether a moveable bridge was properly aligned and locked for train passage did not effectively prepare crews to handle all situations they could potentially encounter in traversing moveable bridges.

8. In its decision to keep the bridge operational even though the bridge continued to malfunction, Consolidated Rail Corporation failed to recognize that the hazards that existed with the moveable bridge operation could not be mitigated by using operating crewmembers to inspect the bridge.

9. The severity and probability of a mishap occurring on the bridge should have prompted Consolidated Rail Corporation to cease bridge opening and closing operations until appropriate mitigation measures were taken.

10. The thickness and material properties of the tank shell and the weld size, quality, and material properties where the breach occurred met the requirements for DOT-105A300W tanks.

11. The tank car shell was punctured by an impact with the lower shelf of the adjacent tank car coupler that exceeded the strength of the tank shell material.

12. During the early hours following the accident, Consolidated Rail Corporation personnel did not immediately provide critical hazardous materials information to emergency responders that could have assisted in executing a safer response to this accident.

13. The American Association of Railroads instruction Consolidated Rail Corporation adopted that directs railroad employees to provide an extra copy of the train consist “when available” does not meet the intent of the requirements found under Title 49 Code of Federal Regulations 172.600, given that train consists frequently contain the emergency response information.

14. Railroad-provided emergency response information that deviates from nationally recognized Emergency Response Guide information has the potential to confuse emergency responders faced with making timely isolation and protective action distance decisions in response to hazardous materials releases.

15. Personnel exposure to vinyl chloride would have been minimized had the incident commander followed guidance contained in the Emergency Response Guide, accepted the advice from hazardous materials emergency responders, and conducted the emergency operations in accordance with Hazardous Waste Operations and Emergency Response standards under Title 29 Code of Federal Regulations 1910.120.

16. The dissemination of inaccurate public information about the release of vinyl chloride revealed the lack of an effective system for communicating to the public accurate information about the current situation following the accident.

17. Although air dispersion modeling tools are readily available, the incident command team did not use any of these tools to evaluate toxic exposure during the first hours following the accident.

18. New Jersey firefighter certification and training requirements were not effective as demonstrated by the failure of emergency responders to conduct operations in accordance with established health and safety protocols and Occupational Safety and Health Administration Hazardous Waste Operations and Emergency Response standards, and their lack of familiarity with available tools to evaluate toxic exposure threats.

19. Had Consolidated Rail Corporation executed an effective public awareness program, the Paulsboro community and emergency response organizations would have been better prepared to safely and effectively respond to the vinyl chloride release.

20. Active participation by railroads in local emergency planning would result in safer and more efficient emergency responses to railroad accidents involving hazardous materials releases.

21. Had the borough of Paulsboro performed an assessment of the emergency response needs and capabilities for the hazardous materials that are present and transiting through its community, it would have been apparent that the emergency response capabilities and plans were inadequate for the types of high consequence incidents that can occur in the jurisdiction.

22. The New Jersey emergency operations plan review process fails to ensure that the emergency operations plan content is based on an adequate emergency response needs and capability assessment, and fails to adequately provide for responses to releases of hazardous materials in transportation.

23. Had Consolidated Rail Corporation performed an adequate hazardous materials transportation route risk assessment, factors such as the characteristics of the moveable bridge, population density, and emergency response capability that caused and/or contributed to the accident would have been identified.

PROBABLE CAUSE

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.

RECOMMENDATIONS

New Recommendations

As a result of this investigation, the National Transportation Safety Board makes the following new safety regulations:

To the Consolidated Rail Corporation:

1. Amend Hazardous Materials Instructions for Rail, HM-1 to require train crews to immediately provide their train consists and the emergency response information for all hazardous materials on the train to federal, state, or local emergency response officials when accidents occur.(R‑14‑XX)

To the US Department of Transportation:

2. Require railroads transporting hazardous materials through communities to provide emergency responders and local and state emergency planning committees with current commodity flow data and assist with development of emergency operations and response plans. (R-14-XX)

To the Federal Railroad Administration:

3. Promulgate a regulation for permitting a train to pass a red signal aspect protecting a moveable bridge that is similar to the criteria for allowing a train to cross a broken rail as contained in Title 49 Code of Federal Regulations (CFR) 213.7(d) to ensure that the bridge has been inspected by a qualified employee before a train is authorized to proceed across the bridge. (R-14-XX)

4. Collaborate with the Pipeline and Hazardous Materials Safety Administration and the American Short Line and Regional Railroad Association to develop a risk assessment tool that addresses the known limitations and shortcomings of the Rail Corridor Risk Management Safety software tool. (R-14-XX)

5. Collaborate with the Pipeline and Hazardous Materials Safety Administration and the American Short Line and Regional Railroad Association to conduct audits of short line and regional railroads to ensure that proper route risk assessments that identify safety and security vulnerabilities are being performed and are incorporated into a safety management system program.(R-14-XX)

To the Pipeline and Hazardous Materials Safety Administration

6. Take action to ensure that emergency response information carried by train crews is consistent with and is at least as protective as existing emergency response guidance provided in the Emergency Response Guidebook. (R-14-XX)

7. Require railroads transporting hazardous materials to develop, implement, and periodically evaluate a public education program similar to Title 49 Code of Federal Regulations Parts 192.616 and 195.440 for the communities along railroad hazardous materials routes. (R-14-XX)

8. Collaborate with the Federal Railroad Administration and the American Short Line and Regional Railroad Association to develop a risk assessment tool that addresses the known limitations and shortcomings of the Rail Corridor Risk Management System software tool. (R-14-XX)

9. Collaborate with the Federal Railroad Administration and the American Short Line and Regional Railroad Association to conduct audits of short line and regional railroads to ensure that proper route risk assessments that identify safety and security vulnerabilities are being performed and are incorporated into a safety management system program. (R-14-XX)

To the Association of American Railroads

10. Amend the United States Hazardous Materials Instructions for Rail to require train crews to immediately provide their train consists and the emergency response information for all hazardous materials on the train to federal, state, or local emergency response officials when accidents occur. (R-14-XX)

11. Update the Hazardous Materials Shipping Descriptions and Emergency Response database to ensure that emergency response information provided for hazardous materials shipments is consistent with and is at least as protective as guidance contained in the Emergency Response Guidebook. (R-14-XX)

To the American Short Line and Regional Railroad Association:

12. Collaborate with the Federal Railroad Administration and the Pipeline and Hazardous Materials Safety Administration to develop a risk assessment tool that addresses the known limitations and shortcomings of the Rail Corridor Risk Management Safety software tool. (R-14-XX)

13. Collaborate with the Federal Railroad Administration and the Pipeline and Hazardous Materials Safety Administration to conduct audits of short line and regional railroads to ensure that proper route risk assessments that identify safety and security vulnerabilities are being performed and are incorporated into a safety management system program. (R-14-XX)

To the International Association of Fire Chiefs:

14. Notify your membership about the circumstances of this accident and develop a plan to incorporate into ongoing training curricula lessons learned concerning the need to promptly use adequate data collection and analysis tools and to develop and implement community protective measures for mitigating the threats of hazardous materials releases. (R-14-XX)

To the National Volunteer Fire Council:

15. Notify your membership about the circumstances of this accident and develop a plan to incorporate into ongoing training curricula lessons learned concerning the need to promptly use adequate data collection and analysis tools and to develop and implement community protective measures for mitigating the threats of hazardous materials releases. (R-14-XX)

To the New Jersey State Police Office of Emergency Management

16. Ensure communities base their emergency operations plan content on hazard analysis and risk assessments that adequately provide for response to hazardous materials threats facing communities, including railroad transportation. (R-14-XX)

17. Develop emergency operations planning recertification and approval procedures with adequate accountability, quality control measures, and audit methods to ensure that communities maintain accurate, appropriate, and current plans. (R-14-XX)

To the New Jersey Bureau of Fire Department Services:

18. Update the firefighter training curricula relating to hazardous materials operations to incorporate lessons learned from this National Transportation Safety Board accident investigation concerning the emergency response to the Conrail Freight Train Derailment with Vinyl Chloride Release in Paulsboro, New Jersey, on November 30, 2012. (R-14-XX)

To the New Jersey Department of Labor and Workforce Development:

19. Develop an emphasis program that incorporates enforcement and outreach activities to ensure New Jersey state and local public sector employee compliance with the Hazardous Waste Operations and Emergency Response regulations. (R-14-XX)

To the New Jersey Department of Health

20. Develop an emphasis program that incorporates enforcement and outreach activities to ensure New Jersey state and local public sector employee compliance with the Hazardous Waste Operations and Emergency Response regulations. (R-14-XX)

Previously Issued Recommendations Reiterated in this Report

As a result of this accident investigation, the National Transportation Safety Board reiterates the following previously issued safety recommendations:

To the Federal Railroad Administration:

1. Require that safety management systems and the associated key principles (including top-down ownership and policies, analysis of operational incidents and accidents, and continuous evaluation and improvement programs) be incorporated into railroad's risk reduction programs required by Public Law 110-432, Rail Safety Improvement Act of 2008, enacted October 16, 2008. (R-12-03)

2. Work together to develop regulations requiring that railroads immediately provide to emergency responders accurate, real-time information about the identity and location of all hazardous materials on a train. (R-07-02)

To the Pipeline and Hazardous Materials Safety Administration:

1. Work together to develop regulations requiring that railroads immediately provide to emergency responders accurate, real-time information about the identity and location of all hazardous materials on a train. (R-07-04)