of the Honorable Christopher A. Hart
National Transportation Safety Board
on Railroads, Pipelines, and Hazardous Materials
on Transportation and Infrastructure
United States House of Representatives
Oversight of the Ongoing Rail, Pipeline, and Hazmat Rulemakings
April 14, 2015
morning Chairman Denham, Ranking Member Capuano,
and the Members of the Subcommittee. Thank you for inviting the National
Transportation Safety Board (NTSB) to testify before you today.
NTSB is an independent Federal agency charged by Congress with investigating
every civil aviation accident and significant incidents in the United States
and significant accidents and incidents in other modes of transportation –
railroad, highway, marine and pipeline. The NTSB determines the probable cause
of accidents and other transportation events and issues safety recommendations
aimed at preventing future accidents. In addition, the NTSB carries out special
studies concerning transportation safety and coordinates the resources of the
Federal Government and other organizations to provide assistance to victims and
their family members impacted by major transportation disasters.
its inception, the NTSB has investigated more than 140,500 aviation accidents
and thousands of surface transportation accidents. In addition, the NTSB has
completed 553 major investigative reports in the areas of railroad, pipeline,
and hazardous materials safety. On call 24 hours a day, 365 days a year, NTSB
investigators travel throughout the country and internationally to investigate
significant accidents and develop factual records and safety recommendations
with one aim—to ensure that such accidents never happen again. The NTSB's
annual Most Wanted List highlights safety-critical actions that the US
Department of Transportation (DOT), United States Coast Guard, other Federal
entities, states, and organizations need to take to help prevent accidents and
date, we have issued over 14,000 safety recommendations to nearly 2,300
recipients. Because we have no formal authority to regulate the transportation
industry, our effectiveness depends on our reputation for conducting thorough,
accurate, and independent investigations and for producing timely,
well-considered recommendations to enhance transportation safety.
January, the NTSB released its Most Wanted List of Transportation Safety
Improvements for 2015. Each year, we develop our Most Wanted List based on
safety issues we identify as a result of our accident investigations. Several
of this year’s Most Wanted List areas involve rail and hazardous materials including
“Improve Rail Tank Car Safety,” “Implement Positive Train Control in 2015,” and
“Make Mass Transit Safer.” Today, I would like to highlight some specific
issues of concern to the NTSB.
Rail Safety: Railroad
Tank Car Design
nation’s railroad network is taking on an expanding role—one that has profound
economic importance—as a major channel for the transportation of crude oil and
other hazardous products. The Association of American Railroads (AAR) states
that crude oil shipments have increased on Class I railroads from 4,700
carloads in 2006 to about 400,000 shipments in 2013 and this growth is expected
to continue for the foreseeable future.
ethanol traffic transported by railroad increased 442 percent between 2005 and
2010. In 2012, ethanol was the most frequently transported hazardous material
in the railroad system. In 2013, more than 290,000 tank cars
transported ethanol. The evolving role of our nation’s railroad
network in the transportation of flammable crude oil and ethanol requires
interested parties to take a comprehensive approach to eliminate or
significantly reduce the safety risks. This approach must include improvements
to railroad track inspection and maintenance programs, crashworthiness of the
tank cars that transport these materials, and information sharing with first
responders when accidents do occur.
as the volume of flammable liquids transported by rail grows, major accidents
such as the December 2013 Casselton, North Dakota, derailment and crude oil
fire have become an increasingly commonplace story.
Multiple recent serious and fatal accidents reflect substantial shortcomings in
tank car design that create an unacceptable public risk. The crude oil unit
train involved in the Casselton accident consisted of railroad tank cars
designed and manufactured to DOT Specification 111-A100W1 (DOT-111)—a design
that presents demonstrated and serious safety concerns when used to transport
hazardous liquids such as crude oil and ethanol. Specifically, the NTSB has
identified vulnerabilities in the DOT-111 tank car design with respect to tank
heads, shells, thermal protection, and fittings that create the unnecessary and
demonstrated risk that can result in the release of the tank car product in an
accident. Flammable liquids such as crude oil and
ethanol frequently ignite and cause catastrophic damage.
NTSB continues to find that accidents involving the rupture of DOT-111 tank
cars carrying hazardous materials often have violent and destructive results.
For example, on July 6, 2013, a 4,700-foot-long train that included 72 DOT-111
tank cars loaded with crude oil from the Bakken fields derailed in
Lac-Mégantic, Quebec, triggering an intense fire fed by crude oil released from
at least 60 cars. The fire engulfed the surrounding area and completely
destroyed the town center. Forty-seven people died. The NTSB assisted the Transportation
Safety Board of Canada (TSB) in its investigation of that accident, and a final
report was issued on August 19, 2014. Both
the NTSB and the TSB issued safety recommendations asking the Federal Railroad
Administration (FRA) and the Pipeline and Hazardous Materials Safety
Administration (PHMSA), as appropriate, to require railroads to evaluate the
safety and security risks of crude oil train routes and select routes that
avoid populous and other sensitive areas; require railroads to develop
comprehensive emergency response plans for worst-case releases resulting from
accidents; and require shippers to sufficiently test and properly classify
hazardous materials such as crude oil prior to shipment.
PHMSA and the FRA continue to work to implement these recommendations.
addition, the NTSB is investigating, has investigated, or is participating in
the investigation of a spate of recent similar accidents in the United States
that demonstrate the destructive results when tank cars containing flammable
liquids are ruptured or exposed to intense pool fires, including:
February 16, 2015, CSX unit train derailment at near Mount Carbon, West
Virginia, 35 miles southeast of Charleston, West Virginia, in which
approximately 28 Casualty Prevention Circular-1232 (CPC-1232)
tank cars in a 109-tank car crude oil unit train derailed and released an
unknown amount of crude oil onto the ground, which immediately ignited. About
300 people were evacuated from within a one-half mile radius of the scene.
April 30, 2014, crude oil until train derailment in Lynchburg, Virginia, in
which three tank cars derailed into the James River and one CPC-1232 tank car breached,
spilling its contents into the river. This accident is still under
July 11, 2012, Norfolk Southern Railway Company train derailment in a Columbus,
Ohio, industrial area in which three derailed DOT-111 tank cars released about
54,000 gallons of ethanol, with energetic rupture of one tank car in a
October 7, 2011, Tiskilwa, Illinois, train derailment of 10 DOT-111 tank cars
resulting in fire, energetic rupture of several tank cars, and the release of
more than 140,000 gallons of ethanol.
June 19, 2009, Canadian National Railway unit train derailment in Cherry
Valley, Illinois, in which 13 of 19 derailed DOT-111 tank cars breached, caught
fire, and released more than 230,000 gallons of ethanol. The post-accident fire
resulted in one death, nine injuries, and the evacuation of 600 houses within
half a mile of the accident site.
October 20, 2006, Norfolk Southern Railway Company unit train derailment in New
Brighton, Pennsylvania, in which 23 DOT-111 tank cars derailed, fell from a
bridge, caught fire, and released more than 485,000 gallons of ethanol.
the use of unit trains increases the risk of catastrophic damage should a
derailment occur. The risks are greater in unit train operations because
hazardous materials are transported in high density. For example, a unit train
of 75 to 100 fully loaded 30,000-gallon tank cars typically transports between
2.1 million and 2.8 million gallons of hazardous materials. The
Mount Carbon, Lynchburg, Casselton, Cherry Valley, and New Brighton accidents
involved unit trains. Improvements in tank car safety would most effectively be
targeted to those hazardous materials commodities that are transported by unit
train, such as denatured fuel ethanol and crude oils, and that pose the
greatest risks when released.
requirements simply have not kept pace with evolving demands placed on the
railroad industry and evolving technology and knowledge about hazardous
materials and accidents. While CPC-1232 provides a level of protection greater
than corresponding Federal requirements, the NTSB is not convinced that these
modifications offer sufficient safety improvements. The
NTSB continues to assert that DOT-111 tank cars, or tank cars of any successor
specification, that transport hazardous materials should be more puncture resistant
and have effective thermal protection systems. This can be accomplished through
the incorporation of additional protective features such as full head shields,
jackets, thermal insulation, appropriate pressure relief devices, and thicker
head and shell materials. Because the average service life of a tank car may
run 20-50 years, it is imperative that industry, the FRA, and PHMSA take action
now to address hazards that otherwise would exist for another half- generation
important decisions are clearly ahead for regulators and industry, the NTSB is
pleased that at least some progress has been made. PHMSA published a notice of
proposed rulemaking (NPRM) in August 2014 proposing safety improvements to
DOT-111 tank cars used in trains hauling 20 or more carloads of Class 3
flammable liquids such as crude oil or ethanol. The NPRM addresses NTSB safety recommendations
to require that general service tank cars authorized for transportation of
denatured fuel ethanol and crude oil have enhanced tank head and shell puncture
resistance systems and top fittings protection that exceed existing design
requirements for DOT-111 tank cars, as well as other improvements. The NPRM also addresses the Lac-Mégantic recommendations
issued in January 2014. We remain engaged in that rulemaking
proceeding. PHMSA submitted a draft final rule to the Office of Management and
Budget for formal review on February 5, 2015, and we will continue to carefully
monitor PHMSA’s progress and will ensure that decision-makers have the full
benefit of the lessons the NTSB has learned through its investigations.
Two weeks ago, the NTSB issued new
recommendations that PHMSA require tank cars used to transport Class 3
flammable liquids be equipped with (1) thermal protection systems and (2) appropriately
sized pressure relief devices that allow the release of pressure under fire
conditions to ensure thermal performance that meets or exceeds the thermal
performance standards outlined in Title 49 CFR § 179.18(a). We
also recommended that PHMSA require an aggressive, intermediate progress
milestone schedule, such as a 20 percent yearly completion metric over a five-year
implementation period, for the replacement or retrofitting of legacy DOT-111
and CPC-1232 tank cars to appropriate tank car performance standards, and that
PHMSA establish a publicly available reporting mechanism that reports, at least
annually, progress on retrofitting and replacing tank cars subject to thermal
protection system performance standards.
are aware of several other accidents in which crude oil releases caused major
environmental damage and fires. These accidents include:
March 27, 2013, derailment of a Canadian Pacific train involving 14 tank cars
of western Canadian crude oil in Parkers Prairie, Minnesota, that released
15,000 gallons of product.
January 31, 2014, derailment of 11 tank cars of a Canadian National (CN) train
transporting North Alberta crude oil in New Augusta, Mississippi, releasing
90,000 gallons of product.
February 13, 2014, derailment of 19 tank cars of a Norfolk Southern train
carrying western Canadian heavy crude oil in Vandergrift, Pennsylvania,
releasing 10,000 gallons of product.
January 7, 2014, derailment of five tank cars of a CN train carrying
western Canadian (Manitoba/Saskatchewan) crude oil in Plaster Rock, New
Brunswick, releasing 60,000 gallons of product.
February 14, 2015, derailment of a CN crude oil unit train with 100 derailed tank
cars 29 cars in a remote area near Gogama, Ontario, while traveling at 38 mph.
Investigators found that 19 of the cars were breached and released more than 264,000
gallons of crude oil.
March 5, 2015, derailment of a BNSF crude oil unit train with 103 tank cars traveling
at 23 miles-per-hour (mph) derailed 21 tank cars in a rural area south of
Galena, Illinois. A post-accident pool fire that began with product released
from damaged valves and fittings on some tank cars resulted in five tank car
March 7, 2015, derailment of a CN crude oil unit with 94 tank cars while
traveling at 43 mph derailed 39 tank cars at the west end of a CN rail bridge
that traversed the Macaming River near Gogama, Ontario, which is about 23 miles
from the above-mentioned February 14, 2015, accident location. Five tank cars
came to rest in the river and the remaining cars piled up on the west side of
the bridge where tank cars were breached, released product, and ignited a large
pool fire that destroyed the rail bridge.
First Responder Notification
When accidents involving hazardous materials
do occur, first responders must have the knowledge to effectively deal with the
aftermath. Following the 2011 ethanol release and fire in Cherry Valley,
Illinois, the NTSB reiterated its 2007 recommendation that PHMSA and the FRA
require railroads to immediately provide emergency responders with accurate,
real-time information on hazardous materials on a train.
More recently, following the
freight train derailment in Paulsboro, New Jersey, in November 2012, the NTSB again
saw the critical importance of providing immediate, accurate information to
first responders about the contents of a derailed tank car and reiterated this
recommendation. In August 2014, the NTSB further recommended that railroads be
required to inform state and local emergency planning committees about the
commodities traveling through their areas and to assist with the development of
emergency response plans.
Any improvement to railroad tank
car safety must proceed hand-in-hand with an improved approach to ensuring
first responders have adequate information to take appropriate life-saving
actions. Although PHMSA indicated it is working to implement the August 2014 recommendation
as part of its rulemaking proceeding to improve DOT-111 tank cars, the
recommendation has been classified “Open—Unacceptable Response” because we
believe emergency responders and local and state emergency planning committees
should have adequate information concerning shipments of all hazardous materials, not just flammable liquids.
Safety: Positive Train Control (PTC)
December 1, 2013, four people lost their lives and 61 others were injured when
a Metro-North commuter train derailed in the Bronx after entering a curve with
a 30 mph speed limit at 82 mph.
We determined the probable cause of the derailment was the engineer’s
noncompliance with the 30 mph speed restriction because he had fallen asleep
due to undiagnosed severe obstructive sleep apnea. A contributing factor was the
absence of a positive train control system that would have automatically
applied the brakes to enforce the speed restriction. This is one of many accidents
that would have been prevented by PTC.
nearly 40 years, the NTSB has investigated numerous train collisions and
over-speed derailments caused by operational errors involving human performance
failures. The NTSB attributed these human performance failures to a variety of factors,
including fatigue, sleep disorders, medications, loss of situation awareness,
reduced visibility, and distractions in the operating cab such as the use of
cell phones. Many of these accidents occurred after train crews failed to
comply with train control signals, follow operating procedures in non-signaled
or “dark” territories, or adhere to other specific operating rules such as
returning track switches to normal position after completing their work at
systems help prevent derailments caused by over-speeding and train-to-train
collisions caused by slowing or stopping trains that are not being operated in
accordance with the signal systems and operating rules. They also help protect
track workers from being struck by trains. The first NTSB-investigated accident
that train control technology would have prevented occurred in 1969, when four
people died and 43 were injured in the collision of two Penn Central commuter
trains in Darien, Connecticut.
The NTSB recommended, in response to that accident, that the FRA study the
feasibility of requiring railroads to install an automatic train control
system, the precursor to today’s PTC systems.
2008, more lives were lost in a PTC-preventable accident when a Metrolink
commuter train and a Union Pacific freight train collided head-on in
Chatsworth, California, killing 25 people and injuring 102 others. The NTSB
concluded that the Metrolink engineer’s use of a cell phone to send text
messages distracted him from his duties. PTC would have prevented that tragedy.
In the aftermath of the Chatsworth accident, Congress enacted the Rail Safety
Improvement Act (RSIA) of 2008, which requires each Class I rail carrier and each
provider of regularly scheduled intercity passenger or commuter rail
transportation to implement a PTC system by December 31, 2015, on each line
over which intercity passenger or commuter service is operated or over which
poison- or toxic-by-inhalation hazardous materials are transported. We know that several rail carriers have
stated that they will not meet the 2015 deadline. This is disappointing.
we continue to see accidents that could be prevented by PTC:
September 2010, near Two Harbors, Minnesota, human error and fatigue
contributed to the collision of two freight trains, injuring five crew members.
April 2011, near Red Oak, Iowa, fatigue contributed to the rear-end collision
of a coal train with a standing maintenance-of-way equipment train, killing two
May 2011, in Mineral Springs, North Carolina, human error contributed to the
rear-end collision of two freight trains, killing two crew-members and injuring
May 2011, in Hoboken, New Jersey, human error contributed to the collision of a
train with the bumping post at the end of the track.
January 2012, near Westville, Indiana, inattentiveness contributed to the
collision of three trains, injuring two crew-members.
June 2012, near Goodwell, Oklahoma, human inattentiveness contributed to the
collision of two freight trains, killing three crew members.
July 2012, near Barton County, Missouri, human error contributed to the
collision of two freight trains, injuring two crew-members.
May 2013, near Chaffee, Missouri, inattentiveness and fatigue contributed to
the collision of two freight trains, injuring two crew-members and causing the
collapse of a highway bridge.
December 2013, near Keithville, Louisiana, human error contributed to the
collision of two freight trains, injuring four crew-members.
2004, in the 29 PTC-preventable freight and passenger rail accidents that the NTSB
investigated, 68 people died, more than 1,100 were injured, and damages totaled
millions of dollars. The NTSB files are filled with accidents that
could have been prevented by PTC, and for each and every day that PTC
implementation is delayed, the risk of an accident remains.
is much debate by policymakers on extending the 2015 deadline established by
the RSIA. Some railroads may meet this deadline. For those railroads that have
made the difficult decisions and invested millions of dollars, they have
demonstrated leadership. For those railroads that will not meet the deadline,
there should be a transparent accounting for actions taken – and not taken – to
meet the deadline so that regulators and policymakers can make informed
Rail Safety: Inward- and Outward-Facing
Audio and Video Recorders in Locomotive Cabs
The December 1, 2013, Metro-North
accident in the Bronx raised questions about the actions of the engineer prior
to the crash. The NTSB has
repeatedly called for railroad
carriers to install
inward- and outward-facing audio
and image recorders
to answer similar questions
that have arisen
in other accidents. Since the 1990s, the NTSB has
recommended that the FRA require audio recorders inside locomotive cabs. In its
investigation of the February 16, 1996, collision between a Maryland Rail
Commuter train and an Amtrak train near Silver Spring, Maryland, in which no
operating crewmembers survived, the NTSB was unable to determine whether
crewmember activities leading up to the accident contributed to the accident.
Audio and image recorders
in locomotives and cab car
operating compartments are critically important because they could
assist NTSB investigators
happened in a train before an accident.
Significantly, these recordings would help
railroad management prevent accidents by identifying safety issues before they lead to injuries and loss of life. The railroads
could use the information to develop
valuable training and coaching
In the NTSB’s investigation of the Bryan, Ohio, railroad
accident in 1999, with no surviving crewmembers, it reiterated this safety
the FRA stated that no action would be taken to implement the recommendation.
Since the FRA’s refusal to act on the recommendation of in-cab audio recorders,
the NTSB has investigated additional accidents in which audio recorders, along
with inward-facing video recorders, would have provided information to help
determine probable cause and improve safety.
The Chatsworth tragedy again made the case crystal-clear for
understanding the activities of crewmembers
in the minutes and
seconds leading up to accidents. Discussing the strong safety case for a requirement for inward-facing cameras in
locomotives, the NTSB noted that:
[i]n all too many accidents,
the individuals directly involved are either
limited in their recollection
of events or, as
in the case of the Chatsworth
accident, are not
available to be
interviewed because of fatal
injuries. In a
number of accidents the
NTSB has investigated, a better knowledge of crewmembers’ actions before an accident would have helped reveal
the key causal factors and
would perhaps have facilitated
of more effective
Accordingly, the NTSB recommended
that the FRA require the installation, in control compartments,
of “crash- and fire-protected inward- and
outward-facing audio and
capable of providing recordings [for at
least 12 hours] to verify that
train crew actions are in accordance with rules and procedures that
to safety as well as
train operating conditions.” The
NTSB also recommended
that the FRA “[r]equire that railroads
regularly review and
use in-cab audio and image recordings . . . to verify that
train crew actions
in accordance with rules and
that are essential
The NTSB reiterated
in its report on the
collision of a BNSF coal
train with the rear
end of a standing BNSF maintenance-of-
equipment train near Red
which resulted in fatal injuries
to the two crewmembers of
the striking train. Damage was
of $8.7 million. As the NTSB
stated in its report,
the accident again
demonstrated the need for in-cab audio
and image recording devices to better understand
(and thereby prevent) serious
crashes that claim the lives of crewmembers, passengers,
and the public.
In response to the December 2013
Metro-North derailment, we issued our longstanding recommendations on this subject directly to
Railroad. On May 14, 2014, Metro-North responded to the
recommendations stating that it had been authorized to procure cameras with
12-hour continuous audio and image recording capability for the locomotives and
operating cabs of its M-7 and M-8 equipment. Metro-North further stated that its Safety
Department would work on integrating the data as part of the Metro-North System
Safety Program Plan, and the recordings would be used for training, efficiency
testing, hazard analysis, and accident investigations. Metro-North has since
advised the NTSB that it intends to install cameras on its entire fleet.
We have been encouraged by the inclusion of these
recommendations in rail safety legislation, and we hope this can be part of a
rail safety legislative proposal that may be considered by this Congress. In
the meantime, we will continue to address
the recommendation on an
individual railroad basis and
with the FRA.
Pipeline Safety: Integrity Management of
Natural Gas Pipelines
March 12, 2014, in East Harlem in New York City, two multi-use, five-story tall
buildings were destroyed by a natural gas explosion and subsequent fire. Eight
people died, more than 48 people were injured, and more than 100 families were
displaced from their homes. On December 17, 2013, natural gas from a cast iron distribution
pipeline leak resulted in the explosion of a two-story apartment building in Birmingham,
Alabama. One person was killed and eight people were injured. While these
explosions remain under NTSB investigation, they are a grim reminder that
efforts to improve pipeline integrity management practices must continue,
particularly for pipelines located in high consequence areas.
are three types of pipeline systems through which gas is transported from the
source to the end users: gathering, transmission, and distribution systems. Gathering
lines transport gas from a production facility to a transmission line, and
transmission lines transport gas from a gathering line to a distribution
There are approximately 298,000 miles of onshore natural gas transmission
pipelines in the United States. Compared to gas distribution pipelines,
transmission pipelines typically have larger diameters and significantly higher
operating pressures. Therefore, the potential impact of a transmission pipeline
incident on its surroundings is high. Transmission pipelines are classified as
either interstate or intrastate. Interstate pipelines are subject to Federal
oversight, and most states assume oversight through PHMSA for intrastate
pipelines. A state must adopt the minimum Federal regulations and also provide
for enforcement sanctions substantially the same as those authorized by the Federal
pipeline safety regulations. Based on mileage, 64 percent of all gas
transmission pipelines are interstate pipelines, while 36 percent are
2004, the operators of these pipelines have been required by PHMSA to develop
and implement integrity management (IM) programs to ensure the integrity of
their pipelines in populated areas (defined as high consequence areas [HCAs])
to reduce the risk of injuries and property damage from pipeline failures. An operator’s IM program is a management
system designed and implemented by pipeline operators to ensure their pipeline
system is safe and reliable. An IM program consists of multiple components,
including procedures and processes for identifying HCAs, determining likely
threats to the pipeline within the HCA, evaluating the physical integrity of
the pipe within the HCA, and repairing or remediating any pipeline defects
found. These procedures and processes are complex and interconnected. Effective
implementation of an IM program relies on continual evaluation and data
integration. The IM program is an ongoing program that is periodically
inspected by PHMSA and/or state regulatory agencies to ensure compliance with
the last six years, the NTSB completed three major gas transmission pipeline
accident investigations where deficiencies with the operators’ IM programs and
PHMSA oversight were identified as a concern.
These three accidents—located in Palm City, Florida; San Bruno, California; and
Sissonville, West Virginia—resulted in eight fatalities, more than 50 injuries,
and 41 homes destroyed with many more damaged. We are also evaluating IM
oversight in the ongoing East Harlem and Birmingham investigations.
this year, the NTSB’s Safety Research Division conducted a safety study to
build upon the results from the completed investigations and use additional
research to identify weaknesses in the implementation of gas transmission
pipeline integrity management programs in HCAs. The study, Integrity Management of Gas Transmission
Pipelines in High Consequence Areas, found that while PHMSA’s gas IM
requirements have kept the rate of corrosion failures and material failures of
pipe or welds low, there is no evidence that the overall occurrence of gas
transmission pipeline incidents in HCA pipelines has declined. The
study identified areas where improvements can be made to further enhance the
safety of gas transmission pipelines in HCAs.
recognize that IM programs are complex and require expert knowledge and
integration of multiple technical disciplines including engineering, material
science, geographic information systems, data management, probability and
statistics, and risk management. This complexity requires pipeline operator
personnel and pipeline inspectors to have a high level of knowledge to
adequately perform their functions. This complexity can make IM program
development, and the evaluation of operators’ compliance with IM program
requirements, difficult. The study helped the NTSB determine that PHMSA
resources in guiding both operators and inspectors need to be expanded and
effectiveness of an IM program depends on many factors, including how well
threats are identified and risks are estimated. This information guides the
selection of integrity assessment methods that discover pipeline system defects
that may need remediation. The study found that aspects of the operators’
threat identification and risk assessment processes require improvement.
Furthermore, the study found that of the four different integrity assessment
methods (pressure test, direct assessment, in-line inspection, and other
techniques), in-line inspection yields the highest per-mile discovery of pipe
anomalies and the use of direct assessment as the sole integrity assessment
method has numerous limitations. Compared to their interstate counterparts,
intrastate pipeline operators rely more on direct assessment and less on
a result of the safety study, the NTSB issued 28 recommendations.
recommendations include developing expanded and improved guidance for operators
and inspectors for:
development of criteria for threat identification and elimination;
of interactive threats; and
knowledge of the critical components associated with risk assessment
NTSB also recommended evaluating and improving gas transmission pipeline
integrity assessment methods, including increasing the use of in-line
inspection and eliminating the use of direct assessment as the sole integrity
assessment method. Other recommendations include: evaluating the effectiveness
of the approved risk assessment approaches for IM programs; developing minimum
professional qualification criteria for all personnel involved in IM programs;
and improving data collection and reporting, including geospatial data, to
support the development of probabilistic risk assessment models and the
evaluation of IM programs by state and Federal regulators.
Pipeline Safety, Regulatory Certainty, and Job Creation Act of 2011
(the 2011 Act) requires PHMSA to conduct an evaluation on (1) whether IM should
be expanded beyond current HCAs, and (2) whether doing so would mitigate the
need for class location requirements for gas transmission pipelines. Consequently,
PHMSA began a series of rulemaking activities to consider whether IM
requirements should be changed, including adding more prescriptive language in
some areas, and whether other issues related to system integrity should be
addressed by strengthening or expanding non-IM requirements. Among the specific
issues PHMSA is considering concerning IM requirements are whether the
definition of an HCA should be revised and whether additional restrictions
should be placed on the use of specific pipeline assessment methods. The
NTSB provided comments and will monitor these rulemakings to ensure PHMSA has
the full benefit of the lessons learned through our investigations and safety
Pipeline Safety: Integrity Management of
Hazardous Liquid Pipelines
As we learned from the July 25, 2010
pipeline rupture in Marshall, Michigan, and the subsequent release of more than
840,000 gallons of crude oil into nearby wetlands, Talmadge Creek, and the
Kalamazoo River, ensuring adequate integrity management programs for pipelines
transporting hazardous liquids remains critically important. No fatalities were
reported from the crude oil spill; however, local residents self-evacuated from
their houses and about 320 people reported symptoms consistent with crude oil
The Marshall, Michigan, spill is among the largest and costliest onshore oil
spills in the United States
determined that the probable cause of the pipeline rupture was corrosion
fatigue cracks that grew and coalesced from crack and corrosion defects under
disbonded polyethylene tape coating, producing a substantial crude oil release
that went undetected by Enbridge’s control center for more than 17 hours. The
rupture and prolonged release were made possible by pervasive organizational
failures at Enbridge and PHMSA’s weak regulation for assessing and repairing
crack indications. Contributing to the accident was PHMSA’s ineffective
oversight of pipeline integrity management programs, control center procedures,
and public awareness. The investigation also determined contributing factors to
the severity of the environmental consequences were (1) Enbridge’s failure to
identify and ensure the availability of well-trained emergency responders with
sufficient response resources, (2) PHMSA’s lack of regulatory guidance for
pipeline facility response planning, and (3) PHMSA’s limited oversight of
pipeline emergency preparedness that led to the approval of a deficient
facility response plan.
NTSB is pleased that PHMSA has made progress in implementing the
recommendations from this investigation, including PHMSA’s development of an
NPRM titled "Pipeline Safety: Safety of On-Shore Hazardous Liquid
Pipelines." Among other things, the NPRM proposes to incorporate, by
reference, consensus standards governing conduct of assessments of the physical
condition of in-service pipelines using inline inspection, internal corrosion
direct assessment, and stress corrosion cracking direct assessment.
also informed us they are considering revisions to the Control Room Management
regulations of the Pipeline Safety Regulations to more explicitly require team
training. PHMSA indicated it plans to consider this option through the NPRM titled
"Pipeline Safety: Operator Qualification, Cost Recovery, and
Other Proposed Changes."
addition, PHMSA issued two advisory bulletins. The first, Advisory Bulletin
2014-01, was issued on January 28, 2014. It notified pipeline operators (1) of the
circumstances of the Marshall, Michigan, pipeline accident, and (2) of the need
to identify deficiencies in facility response plans and to update these plans
as necessary to conform with the nonmandatory guidance for determining and
evaluating required response resources as provided in Appendix A of Title 49 Code
of Federal Regulations Part 194, “Guidelines for the Preparation of
Response Plans.” The second, Advisory Bulletin 2014-02, was issued on May 6,
2014. It was directed to all hazardous liquid and
natural gas pipeline operators, and it described the circumstances of the
accident in Marshall, Michigan—including the deficiencies observed in Enbridge
Incorporated’s integrity management program—and asked them to take appropriate
action to eliminate similar deficiencies.
Hazardous Materials Safety: Air
Transportation of Lithium Batteries
are two types of lithium batteries: primary and secondary. Primary lithium
batteries are non-rechargeable and are commonly used in items such as watches
and pocket calculators. They contain metallic lithium that is sealed in a metal
casing. The metallic lithium will burn when exposed to air if the metal casing
is damaged, compromised, or exposed to sustained heating. Secondary lithium
batteries, also known as lithium-ion batteries, are rechargeable and are
commonly used in items such as cameras, cell phones, laptop computers, and hand
power tools. Secondary lithium batteries contain electrically charged lithium
ions, and a flammable liquid electrolyte. External damage or overheating of the
battery can result in thermal runaway or the discharge of flammable electrolyte.
Another type of secondary battery, known as lithium polymer batteries, contains
a flammable polymeric material rather than a liquid, as the electrolyte. Halon
suppression systems, the only fire suppression systems certified for aviation, can
be used to help control flames in lithium battery fires but will not suppress thermal
demand for primary and secondary lithium batteries has skyrocketed since the
mid-1990s as the popularity and use of electronic equipment of all types has
grown. As the use of lithium batteries has increased, the number of incidents
involving fires or overheating of lithium batteries, particularly in aviation,
has likewise grown. The NTSB has investigated three such aviation accidents:
Los Angeles, California; Memphis, Tennessee; and Philadelphia, Pennsylvania.
The fires in these accidents
included both primary and secondary lithium batteries, and the NTSB issued
several recommendations as a result of these investigations. As a result of its
investigation of the Los Angeles and Memphis incidents, the NTSB recommended
that PHMSA, with the FAA, evaluate the fire hazards posed by lithium batteries
in an aviation environment and require that appropriate safety measures be
taken to protect the aircraft and occupants. The NTSB also recommended that
packages containing lithium batteries be identified as hazardous materials,
including appropriate labeling of the packages and proper identification in
shipping documents when transported on aircraft. These recommendations have
been closed with acceptable action by the regulators.
Following the Philadelphia accident,
the NTSB issued six safety recommendations urging PHMSA to address the problems
with lithium batteries on a number of fronts, including reporting all
incidents; retaining and analyzing failed batteries; researching the modes of failure;
and eliminating regulatory provisions that permit limited quantities of these
batteries to be transported without labeling, marking, or packaging them as
hazardous materials. In January 2008, the NTSB issued additional
recommendations to PHMSA and the FAA to address the NTSB’s concerns about the
lack of public awareness about the overheating and ignition of lithium
batteries. PHMSA issued an NPRM in
January 2010 to address some of these recommendations, and the final rule was
issued in August 2014. The final rule is discussed in further detail below.
In September 2010, a Boeing
747-400F, operated by UPS, crash landed on a military base in Dubai, United
Arab Emirates (UAE), while the crew was trying to return to the airport for an
emergency landing due to a fire in the main deck cargo compartment. Both
crewmembers died as a result of injuries sustained during the crash, and the
aircraft was a total loss. The UAE led this investigation,
and issued a final report on July 24, 2013. The report found that at least three
shipments of lithium ion battery packs that meet Class 9 hazardous material
designation were onboard. In addition, in July 2011, a Boeing 747-400F,
operated by Asiana Cargo and transporting a large quantity of lithium
batteries, crashed about 70 miles west of Jeju Island, Republic of Korea,
after the flight crew declared an emergency due to a cargo fire and attempted
to divert to Jeju International Airport. Again, both crewmembers died as result
of injuries sustained during the crash, and the aircraft was a total loss.
NTSB held a public forum in April 2013 on lithium ion batteries in
transportation. We learned that lithium ion batteries are becoming more
prevalent in the various transportation modes, national defense, and space
exploration. Panelists stated that because of their high energy density and
light weight, these batteries are natural choices for energy. These benefits,
however, also are the source of safety risks. We also heard about manufacturing
auditing, robust testing, and monitoring and protection mechanisms to prevent a
Congress passed H.R. 658, the FAA Reauthorization bill in 2012, it contained a
provision that US hazardous materials regulations (HMR) on the air
transportation of lithium metal cells or batteries or lithium ion cells or
batteries could not exceed the International Civil Aviation Organization (ICAO)
Technical Instructions for the Safe
Transport of Dangerous Goods by Air. Consequently, in January 2013, PHMSA published
an NPRM stating that it was considering harmonizing requirements in the HMR on
the transportation of lithium batteries with changes adopted in the 2013–2014
ICAO Technical Instructions and requested additional comments on (1) the effect
of those changes, (2) whether to require compliance with the ICAO Technical
Instructions for all shipments by air, both domestic and international, and (3)
the impacts if PHMSA failed to adopt specific provisions in the ICAO Technical
Instructions into the HMR. In the NTSB’s
comments on the NPRM, we noted the disparity between requirements in the HMR,
which had weaker standards at the time, and the ICAO Technical
Instructions. We explained that failure to require domestic shipments of
lithium batteries to comply with regulations equivalent to the ICAO Technical
Instructions would place the United States in an inexplicable position of
having weaker safety standards at a time when it should be leading the way in
response to serious safety concerns about transporting these materials. PHMSA’s
final rule harmonized the HMR with the ICAO Technical Instructions as well as
with applicable provisions of the United Nations Model Regulations and the International
Maritime Dangerous Goods (IMDG) Code.
NTSB notes the DOT has for some years worked to ensure that the US hazardous
materials regulations are compatible with international standards and,
accordingly, has been very active in the development of international standards
for the transportation of hazardous materials. However, the DOT has never
relinquished its rulemaking authority to an international body. The NTSB
concurs with that position and firmly believes the DOT should implement more
stringent standards in US regulations if deemed necessary.
Chairman, the NTSB has a long record of support for improved tank car design, PTC,
inward- and outward-facing recorders in locomotive cabs, improved pipeline
integrity management, and safe transportation of lithium batteries. As you
know, our mission is to promote safety, and the implementation of our
recommendations in these areas would help promote and improve safety.
you for the opportunity to testify before you today. I look forward to
responding to your questions.
FRA Emerg. Order No. 28, 78 Fed. Reg. at 48221; see also NTSB, Letter to The Honorable
Cynthia L. Quarterman, Administrator, Pipeline and Hazardous Materials Safety
Administration, U.S. Department of Transportation (Jan. 21, 2014), at 7 n.
11-13 (and citations therein).
NTSB, 2015 Most Wanted List: Improve Rail Tank Car Safety, (2015).
NTSB, Derailment of CN Freight Train U70691-18 With Subsequent Hazardous
Materials Release and Fire Cherry Valley, Illinois, June 19, 2009, Rpt. No.
NTSB/RAR-12/01 (Feb. 14, 2012), at 88 (concluding that, in accident involving
breaches of DOT-111 tank cars, “If enhanced tank head and shell
puncture-resistance systems such as head shields, tank jackets, and increased
thicknesses had been features of the DOT-111 tank cars
involved in this accident, the release of hazardous materials likely would have
been significantly reduced, mitigating the severity of the accident”). The
capacity of a tank car is about 30,000 gallons or 675 barrels of oil.
Transportation Safety Board
of Canada, Runaway and Main-Track Derailment, Montreal, Maine & Atlantic
Railway Freight Train MMA-002, Mile 0.23, Sherbrooke Subdivision, Lac-Mégantic,
Quebec, 06 July 2013 (2014).
R-14-1, R-14-2, R-14-3, R-14-4,
R-14-5, and R-14-6.
In 2011, AAR issued CPC-1232,
which outlines new standards for tank cars constructed after October 1, 2011,
for use in ethanol and crude oil service. These standards, for example, call
for DOT-111 tank cars that transport flammable liquids in packing groups I and
II (the highest-risk of the three packing groups, classified according to flash
and boiling points) to be built with protective “jackets” around their tanks,
constructed of normalized steel at least 7/16 inch thick, and call for
non-jacketed tanks to be constructed from normalized steel (steel that has been
subjected to a heat-treating process that improves its material properties) at
least half an inch thick. See AAR, Manual of Standards and Recommended
Practices: Specifications for Tank Cars, M-1002. Corresponding Federal
regulations require steel thickness of at least 7/16 inch, but they allow for
the use of non-normalized steel and do not require incorporation of jackets or
head shields. See 49 C.F.R. part 179,
NTSB, Comments on PHMSA notice
of proposed rulemaking: Hazardous Materials: Enhanced Tank Car Standards and
Operational Controls for High-Hazard Flammable Trains, (September 26, 2014), at
79 Fed. Reg. 45016 (August 1,
R-14-1, R-14-3, R-14-4, and
The NTSB is an observer to the
Transportation Safety Board (TSB) of Canada’s investigation.
NTSB, Metro North Railroad Derailment, Accident Brief No. RAB-14/12
(October 24, 2014).
NTSB, Penn Central Company, Collision of Trains N-48 and N-49 on August 20,
1969, Rpt. No. RAR-70-03 (October 14, 1970).
Safety Improvement Act of 2008, Pub. L. No. 110-432, § 104 (2008).
These accidents do not include
NTSB, Collision and
Derailment of Maryland Rail Commuter Marc Train 286 and National Railroad Passenger
Corporation Amtrak Train 29 Near Silver Spring, Maryland On February 16,1996, Rpt.
No. NTSB/RAR-97/02 (July 3, 1997), R-97-9.
NTSB, Collision Involving Three Consolidated Rail Corporation
Freight Trains Operating in Fog on a Double Main Track Near Bryan, Ohio on
January 17, 1999, Rpt. No. NTSB/RAR-01/01 (May 9, 2001).
NTSB, Collision of Metrolink Train 111 With Union Pacific Train LOF65-12
Chatsworth, California September 12, 2008, Rpt. No. NTSB/RAR-10/01 (Jan.
21, 2010), at 58.
NTSB, Collision of BNSF Coal Train With the Rear End of Standing BNSF
Maintenance-of-Way Equipment Train Red Oak, Iowa on April 17, 2011), Rpt.
No. NTSB/RAR-12/02 (April 24, 2012).
NTSB, Columbia Gas Transmission Corporation Pipeline Rupture Sissonville,
West Virginia on December 11, 2012,
Rpt. No. NTSB/PAR-14/01 (February 19, 2014); NTSB, Rupture of Florida Gas Transmission Pipeline and Release of Natural Gas
Near Palm City, Florida, Accident Brief No. NTSB/PAB-13/01 (August 13,
2013); NTSB, Pacific Gas and Electric
Company Natural Gas Transmission Pipeline Rupture and Fire San Bruno,
California on September 9, 2010,
Rpt. No. NTSB/PAR-11/01 (August 30, 2011).
NTSB, Integrity Management of Gas Transmission Pipelines in High Consequence
NTSB/SS-15/01 (January 27, 2015).
L. No. 112-90, § 5 (2012).
NTSB, Enbridge Incorporated Hazardous Liquid Pipeline Rupture and Release
Marshall, Michigan on July 25, 2010, Rpt. No. NTSB/PAR-12/01 (July
75 Fed. Reg. 1302 (January 11,
investigative entities have authority equivalent to the NTSB under ICAO Annex
13. For this accident, in particular, the NTSB has been involved as the
accredited representative as the State of Operator, Registration, and
Manufacturer. The operator, manufacturers, and regulator (FAA) are technical
advisors to the NTSB accredited representative. The NTSB plans to issue
recommendations based on the findings of the UAE investigation.
General Civil Aviation Authority of the United Arab Emirates,
Uncontained Cargo Fire Leading to Loss of Control Inflight and Uncontrolled
Descent into Terrain, (July 24, 2013). Available at http://www.gcaa.gov.ae/en/ePublication/admin/iradmin/Lists/Incidents%20Investigation%20Reports/Attachments/40/2010-2010%20-%20Final%20Report%20-%20Boeing%20747-44AF%20-%20N571UP%20-%20Report%2013%202010.pdf
78 Fed. Reg. 1119 (January 7,
79 Fed. Reg. 46012 (August