Railroad Accident Report

Collision of Norfolk Southern Freight Train 192 With Standing Norfolk Southern Local Train P22
With Subsequent Hazardous Materials Release

Graniteville, South Carolina
January 6, 2005

NTSB Number: RAR-05-04
NTIS Number: PB2005-916304
Adopted November 29, 2005
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Executive Summary

About 2:39 a.m. eastern standard time on January 6, 2005, northbound Norfolk Southern Railway Company (NS) freight train 192, while traveling about 47 mph through Graniteville, South Carolina, encountered an improperly lined switch that diverted the train from the main line onto an industry track, where it struck an unoccupied, parked train (NS train P22). The collision derailed both locomotives and 16 of the 42 freight cars of train 192, as well as the locomotive and 1 of the 2 cars of train P22. Among the derailed cars from train 192 were three tank cars containing chlorine, one of which was breached, releasing chlorine gas. The train engineer and eight other people died as a result of chlorine gas inhalation. About 554 people complaining of respiratory difficulties were taken to local hospitals. Of these, 75 were admitted for treatment. Because of the chlorine release, about 5,400 people within a 1-mile radius of the derailment site were evacuated for several days. Total damages exceeded $6.9 million.

Probable Cause

The National Transportation Safety Board determines that the probable cause of the January 6, 2005, collision and derailment of Norfolk Southern train 192 in Graniteville, South Carolina, was the failure of the crew of Norfolk Southern train P22 to return a main line switch to the normal position after the crew completed work at an industry track. Contributing to the failure was the absence of any feature or mechanism that would have reminded crewmembers of the switch position and thus would have prompted them to complete this final critical task before departing the work site. Contributing to the severity of the accident was the puncture of the ninth car in the train, a tank car containing chlorine, which resulted in the release of poisonous chlorine gas.

The safety issues identified in this investigation are as follows:

Recommendations

As a result of its investigation of the January 6, 2005, collision and derailment of Norfolk Southern train 192 in Graniteville, South Carolina, the National Transportation Safety Board makes the following safety recommendations:

To the Federal Railroad Administration:

Require that, along main lines in non-signaled territory, railroads install an automatically activated device, independent of the switch banner, that will, visually or electronically, compellingly capture the attention of employees involved with switch operations and clearly convey the status of the switch both in daylight and in darkness. (R-05-14)

Require railroads, in non-signaled territory and in the absence of switch position indicator lights or other automated systems that provide train crews with advance notice of switch positions, to operate those trains at speeds that will allow them to be safely stopped in advance of misaligned switches. (R-05-15)

Require railroads to implement operating measures, such as positioning tank cars toward the rear of trains and reducing speeds through populated areas, to minimize impact forces from accidents and reduce the vulnerability of tank cars transporting chlorine, anhydrous ammonia, and other liquefied gases designated as poisonous by inhalation. (R-05-16)

Determine the most effective methods of providing emergency escape breathing apparatus for all crewmembers on freight trains carrying hazardous materials that would pose an inhalation hazard in the event of unintentional release, and then require railroads to provide these breathing apparatus to their crewmembers along with appropriate training. (R-05-17)