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 â€“
whether paid or volunteer â€“ 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
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
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
The hearing will address key issues of the investigation through four panels.
These four panels are:
- CONRAIL Bridge Operations;
- Initial Emergency Response;
- Hazardous Materials Incident Management; and
- State and Federal Emergency Response Actions;
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.
- Mr. Paul Stancil, Investigator in Charge
- Mr. Matt Nicholson, Hearing Officer
Our technical panelists include:
- Mr. Steve Blackistone
- Mr. Larry Bowling
- Mr. Richard Downs
- Mr. Muhamed El-Zoghbi
- Mr. Erik Grosof
- Dr. Gary Helmer
- Dr. Stephen Jenner
- Mr. Jim Southworth
- Mr. Paul Stancil
- Mr. Ted Turpin
- Mr. John Vorderbrueggen
- Mr. Dave Watson
Additional support is provided by:
- Mr. Terry Williams will be handling Public Affairs,
- Ms. Ann Gawalt, Ms. Shannon Bennett and Mr. Alex Burkett will provide legal
- Ms. Nancy Mason will be providing administrative support, and
- Ms. Jennifer Cheek and Ms. Stephanie Davis will be handling the
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.
- Federal Railroad Administration, Mr. Ron Hynes
- Pipeline and Hazardous Materials Safety Administration, Mr. William
- Consolidated Rail Corporation (Conrail), Mr. Neil Ferrone
- United States Coast Guard, Captain David Fish
- Borough of Paulsboro, New Jersey, Chief Alfonso Giampola
- State of New Jersey, Mr. David Sweeney
- Brotherhood of Locomotive Engineers and Trainmen, Mr. William Walpert
- United Transportation Union, Mr. William Bates
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
We will then proceed in sequence, one panel at a time for each hearing
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
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
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.
(Matt Nicholson to run-through housekeeping and then introduce the
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.