Vice Chairman Christopher A. Hart
Good morning, I am Chris Hart, Vice Chairman of the National Transportation Safety Board. I am joined by my fellow Board Members: Member Robert Sumwalt and Member Mark Rosekind.
As you may know, Chairman Hersman is the Board Member on scene in San Francisco at the site of the crash of Asiana Airlines Flight 214. Member Earl Weener is not here today because he is also leading a Go Team in Alaska to investigate the crash of a DeHavilland Otter that claimed 10 lives. On behalf of the entire NTSB staff, I extend our condolences to the families who lost loved ones in the San Francisco and Alaska accidents. We continue to hope for the recovery of those who were injured in the Asiana accident.
Much of this investigative hearing will be examining the roles and responsibilities of first responders. It is only fitting that we recognize the dedication and professionalism of the men and women in our local communities – whether paid or volunteer – who put themselves on the front lines of safety to protect our communities. As we painfully witnessed in the last week with the loss of 19 firefighters in Arizona, there is great risk and sacrifice associated with being a first responder or a family member of a first responder. All of us at the NTSB salute those 19 fallen firefighters and their families during this difficult time. And, we offer a collective thank you to all the first responders who are here today for their professionalism and self-sacrifice on our behalf.
At 6:49 a.m. eastern standard time on November 30, 2012, a westbound Conrail freight train, FC4230, approached and stopped at a red signal ahead of a moveable bridge spanning Mantua Creek in Paulsboro, New Jersey. Following several unsuccessful attempts by the train crew to clear the signal, the crew received permission from the train dispatcher to proceed past the stop signal and over the bridge. At about 7:00 a.m., while crossing Mantua Creek, the locomotive engineer felt the emergency brake activate and watched in the side mirror as seven cars, including five hazardous- materials tank cars, derailed from the bridge tracks; some falling into the creek.
Four of the derailed tank cars contained vinyl chloride, a known carcinogen and highly flammable chemical. The shell of one of these tank cars was breached during the derailment releasing approximately 20,000 gallons of liquid vinyl chloride into Mantua Creek where it vaporized, creating a large white cloud that was dispersed with the prevailing winds. Twenty-three people were treated that day at nearby hospitals for symptoms of vinyl chloride exposure. Additional emergency responders and members of the public have since sought treatment for possible vinyl chloride exposure.
The local emergency responders were made aware of the release soon after the accident and established an incident command close to the accident site and in the vapor cloud. Evacuation orders initially were issued to the community but later replaced by recommendations to shelter-in-place. While some emergency response organizations were aware of the released chemical and its dangers, communications were inconsistent and, at times, referred to the release as non-toxic.
Throughout the morning of November 30, the incident command post remained near the ruptured vinyl chloride tank car, and first responders, including Conrail employees, continued to inspect the accident site and wreckage without wearing personal protective gear to prevent overexposure to the vinyl chloride. Later that afternoon a Unified Command was formed and the incident command post was moved farther away from the release. The Unified Command also reinstated a community evacuation order when data from the air monitoring activities indicated unsafe vinyl chloride vapor concentrations.
The NTSB is holding this hearing to understand how Conrail ensures the safe operation of moveable bridges and safe crossing. In addition, this hearing will seek to understand the actions and decisions that took place during the initial emergency response in Paulsboro, New Jersey. We are here to find out what information was available to the emergency responders and what actions were taken to protect the first responders and the community from the release. Furthermore, we will discuss available standards for training first responders, best practices for hazardous materials releases, and state and federal responsibilities with respect to hazardous materials incident response.
As part of our investigation, the NTSB is looking to identify from this hearing the key safety lessons learned from the actions, decisions, and communications during this response so that other emergency responders and communities will be better prepared in the future.
There is always some risk when large quantities of hazardous materials are transported through our communities or through environmentally sensitive areas. It is important to understand whether rail operators are applying sufficient operational safeguards to counter these risks and whether the hazardous materials emergency responders have the knowledge, guidance, equipment, procedures, and training to keep pace with a multitude of potential threats from hazardous materials releases.
Over the next two days we will be asking: How are moveable bridges kept safe and what are the operational measures put in place to ensure operating crews can safely cross bridges? How do emergency responders assess the dangers of a hazardous materials release? What information do first responders have, or need, to take protective action following a hazardous materials release? What actions should the first responders take to an unknown chemical threat? And, what role do the state and federal agencies play during a hazardous material release to protect the workers and community?
On June 27, 2013, the NTSB conducted a pre-hearing conference attended by the Technical Panel, the parties to this hearing, and me as the Chairman of this Board of Inquiry. At the conference, we delineated the topics to be discussed at this hearing, and identified and agreed upon the list of witnesses and exhibits.
The hearing will address key issues of the investigation through four panels. These four panels are:
The primary emphasis of the hearing is on the hazardous materials release and the emergency response that followed. There will be discussion of bridge operations, operating rules, and train operations traversing the bridge. Topics related to the specifics of the bridge structure, tank car design, and the crashworthiness and performance of tank cars will not be addressed at the hearing. In addition, the hearing questioning will be limited to events that occurred during the first day of the accident response on November 30, 2012.
Testimony and questioning will be limited to the topics identified and agreed upon. I'd like to underscore we are still in the fact-finding stage of the NTSB investigation. This hearing allows us to supplement the facts, conditions and circumstances related to the incident, and identify what can be done to prevent similar incidents. Before proceeding, I'd like to recognize the NTSB staff members who are part of this hearing.
Our technical panelists include:
Additional support is provided by:
I will now introduce the parties designated to participate in the investigative hearing. As prescribed in the NTSB rules, we designate as parties those organizations or individuals whose participation we deem necessary in the public interest and whose special knowledge will contribute to the development of pertinent evidence.
As I call the name of the party, I ask the designated spokesperson to identify themselves, their affiliation with the party they represent, and introduce those other persons at their party's table.
I'd like to thank all of the parties for their assistance and cooperation with the NTSB investigation thus far. There is still more work to be done in the investigation, but we appreciate your valuable time and we look forward to working with you as the investigation moves forward.
We will begin the hearing with a presentation by the Investigator-In-Charge, Paul Stancil, who will provide an overview of the accident and investigation.
We will then proceed in sequence, one panel at a time for each hearing issue.
For each panel, Mr. Nicholson will call and introduce the witnesses, and each will testify under oath. The witnesses have been pre-qualified and their qualifications and biographical information are available on the NTSB website.
The witnesses will be questioned first by the NTSB technical panel, then by the spokesperson for each party, and finally by the Board of Inquiry.
Presentations should be kept between 5 to 8 minutes in length. The witnesses giving testimony and each person who asks questions will be limited to 5 minutes. After one round of questions, due to time constraints, a second round will be limited to pertinent questions that serve to clarify the record or to address some new matter raised.
I must emphasize the fact-finding nature of the hearing. NTSB investigations are, by regulation, fact-finding proceedings with no adverse parties. The Board does not assign fault or blame for an accident or incident. At this hearing, witnesses may not speculate or analyze the facts. Questions are limited to the predetermined subject matter of the hearing, which is contained in the hearing agenda. Questions related to fault, outside litigation, or legal liability in general will not be permitted.
The exhibits contain redactions, noted with a grey box, which were the result of negotiations between the parties and the NTSB regarding the disclosure of information claimed to be personally identifiable information or business confidential. The NTSB is authorized by statute to disclose information to carry out its mission, but we must do so in a way that protects the confidentiality to the greatest extent possible. While the NTSB has access to all of the information, the exhibits disclose to the public relevant materials that are part of the investigation and/or will be discussed at the hearing. A white paper explaining our authority to use proprietary information is available on the NTSB website.
At this time I will call on the Hearing Officer Matt Nicholson to go over housekeeping items and to describe the exhibits to be used during the hearing. Mr. Nicholson.
(Matt Nicholson to run-through housekeeping and then introduce the exhibits.)
Thank you, Mr. Nicholson.
Mr. Stancil, will you now provide a description of the accident.
(Paul Stancil gives opening presentation.)
Now, I will call on the hearing officer to call and qualify the first witnesses. Mr. Nicholson.