In closing, I want to recognize again the NTSB staff for their hard work in
developing and presenting this excellent report. Investigator-in-Charge Paul
Stancil and the whole investigative team did an outstanding job despite often
challenging conditions. I also want to thank my fellow Board Members for their
very helpful participation in the process. And once again I would like to
acknowledge the presence in this audience of the current Chief, and the former
Deputy Chief of the Paulsboro Fire Department, and the Captain of the Paulsboro
Police Department. I would like to thank the town of Paulsboro for its
assistance in this investigation.
The new recommendations in this report, if acted upon, will make rail
transportation safer – especially rail transportation of hazardous
We have asked the Federal Railroad Administration to write a regulation about
passing a red signal on a moveable bridge, analogous to existing regulations for
passing a broken rail – another danger that clearly demands respect.
In addition, if there is a release of hazardous materials despite the
safeguards, responders must be trained and prepared to use the best available
guidance to protect their community.
We have also recommended that railroads be required to help communities along
their routes to better prepare and train for hazardous materials
We have recommended that new risk assessment tools be developed to address
known deficiencies in the tools available today.
And we have made recommendations to the State Police Office of Emergency
Management and other agencies in the State of New Jersey.
If implemented, these recommendations will help ensure that local Emergency
Operations Plans anticipate the hazards that are likely to be confronted in a
Finally, we hope that recommendations that we issued prior to this accident,
and that we reiterated today, will also be acted upon.
In 2007, we first recommended that the FRA work with the Pipeline and
Hazardous Materials Safety Administration to require that railroads provide
emergency responders accurate, real-time information regarding the identity and
location of all hazardous materials on a train.
Today we reiterated this recommendation. We also recommended that Conrail
amend its Hazardous Materials Instructions for Rail, to incorporate the same
Making this communication mandatory across the rail industry will enable
first responders to have access to the information that they need.
And we eagerly await progress on another reiterated recommendation, that the
FRA require railroads to implement safety management systems or SMS.
An SMS has been defined as "an organized approach to managing safety,
including the necessary organizational structures, accountabilities, policies,
With an effective SMS in place, a bridge with a history of repeated and
uncorrected malfunctions would be viewed as an unacceptable hazard. Instead, the
bridge – and its red signal – came to be treated as a nuisance. This Board has
seen accident after accident where an effective SMS could have prevented
injuries or saved lives.
We learned many lessons for the first time from this accident. Other lessons
had already been learned, yet were not adequately heeded, helping to bring about
this accidentâ€™s monetary and human costs.
Journalist Norman Cousins wrote that "history is a vast early-warning
We hope that the events that led to this derailment, and the issues
surrounding the emergency response, are treated as such a warning.
If the recommendations in this report are acted upon, we can enable the
movement of hazardous materials while avoiding future accidents such as this
We stand adjourned.