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Safety Recommendation Details

Safety Recommendation R-12-007
Details
Synopsis: About 8:36 p.m., central daylight time, on Friday, June 19, 2009, eastbound CN freight train U70691-18, traveling at 36 mph, derailed at a highway/rail grade crossing in Cherry Valley, Illinois. The train consisted of 2 locomotives and 114 cars, 19 of which derailed. All of the derailed cars were tank cars carrying denatured fuel ethanol, a flammable liquid. Thirteen of the derailed tank cars were breached or lost product and caught fire. At the time of the derailment, several motor vehicles were stopped on either side of the grade crossing waiting for the train to pass. As a result of the fire that erupted after the derailment, a passenger in one of the stopped cars was fatally injured, two passengers in the same car received serious injuries, and five occupants of other cars waiting at the highway/rail crossing were injured. Two responding firefighters also sustained minor injuries. The release of ethanol and the resulting fire prompted a mandatory evacuation of about 600 residences within a 1/2-mile radius of the accident site. Monetary damages were estimated to total $7.9 million. The NTSB determined that the probable cause of the accident was the washout of the track structure that was discovered about 1 hour before the train’s arrival, and CN’s failure to notify the train crew of the known washout in time to stop the train because of the inadequacy of the CN’s emergency communication procedures. Contributing to the accident was the CN’s failure to work with Winnebago County to develop a comprehensive storm water management design to address the previous washouts in 2006 and 2007. Contributing to the severity of the accident was the CN’s failure to issue the flash flood warning to the train crew and the inadequate design of the DOT-111 tank cars, which made the cars subject to damage and catastrophic loss of hazardous materials during the derailment.
Recommendation: TO THE PIPELINE AND HAZARDOUS MATERIALS SAFETY ADMINISTRATION: Require that all newly manufactured and existing tank cars authorized for transportation of hazardous materials have center sill or draft sill attachment designs that conform to the revised Association of American Railroads’ design requirements adopted as a result of Safety Recommendation R-12-9.
Original recommendation transmittal letter: PDF
Overall Status: Open - Acceptable Response
Mode: Railroad
Location: Cherry Valley, IL, United States
Is Reiterated: No
Is Hazmat: No
Is NPRM: No
Accident #: DCA09MR006
Accident Reports: ​Derailment of CN Freight Train U70691-18 With Subsequent Hazardous Materials Release and Fire
Report #: RAR-12-01
Accident Date: 6/19/2009
Issue Date: 3/2/2012
Date Closed:
Addressee(s) and Addressee Status: PHMSA (Open - Acceptable Response)
Keyword(s): Hazmat

Safety Recommendation History
From: PHMSA
To: NTSB
Date: 11/9/2016
Response: -From Marie Therese Dominguez, Administrator: As previously mentioned, PHMSA and FRA are both participating in the RSAC Hazardous Materials Issues Working Group. This working group seeks to address two priority issues: (1) hazardous material train car separation requirements ("buffer cars"), and (2) incorporation into the Hazardous Materials Regulations (HMR) of an updated version of AAR' s Manual of Standards and Recommended Practices, Section C Part III, Specifications for Tank Cars (M-1 002). The next meeting will be held in January 2017. If the working group reaches an agreement in that meeting, the next opportunity for a consensus vote from the_ full RSAC will be in April2017. We note that Safety Recommendation R-12-9, as referenced in Safety Recommendation R-12-7, was issued to AAR and subsequently closed based on their acceptable action. Specifically, AAR amended section 6.1.2.7 ofM-1002 to include new design standards (for new construction only) for transverse welds on sill reinforcing plates. Updating the most current edition ofM-1002 into the HMR will capture the revised design standards and satisfy the intent of Safety Recommendation R -12-7.

From: NTSB
To: PHMSA
Date: 12/5/2013
Response: The National Transportation Safety Board (NTSB) has reviewed the Pipeline and Hazardous Materials Safety Administration’s (PHMSA) September 6, 2013, advance notice of proposed rulemaking (ANPRM), “Hazardous Materials: Rail Petitions and Recommendations to Improve the Safety of Railroad Tank Car Transportation.” In this notice, PHMSA is considering revisions to the Hazardous Materials Regulations (HMR) that are based on eight petitions received from the regulated community and four NTSB safety recommendations. The notice requested public comments on whether the proposed amendments would enhance safety and would revise and clarify the HMR with regard to rail transport. Implementing these recommendations, as well as the other listed petitions in the ANPRM that address tank car design improvements, will significantly improve hazardous materials transportation safety. Among the proposed amendments to the HMR are enhanced design standards for specification DOT-111 tank cars used to transport Packing Group (PG) I and II hazardous materials. Three of the four NTSB recommendations listed in the ANPRM directly address improving the tank car standards for transporting hazardous liquids. The fourth NTSB recommendation listed in the ANPRM asks PHMSA to improve the hazardous materials documentation and information that is provided to emergency responders. Based on previous and ongoing NTSB accident investigations, the documented poor accident performance of existing specification DOT-111 tank cars continues to raise serious concerns about the safety of communities, emergency responders, and other individuals who may come in contact with flammable hazardous materials transported in these cars. The NTSB would like to take this opportunity to emphasize the importance of the expeditious implementation of four Safety Recommendations—R-12-5, R-12-6, R-12-7, and reiterated R-07-4—that were issued as a result of the June 19, 2009, derailment of an ethanol unit train of DOT-111 tank cars in Cherry Valley, Illinois. All four safety recommendations are addressed in the ANPRM. These safety recommendations urge PHMSA to take the following actions: Require that all newly manufactured and existing general service tank cars authorized for transportation of denatured fuel ethanol and crude oil in Packing Groups I and II have enhanced tank head and shell puncture resistance systems and top fittings protection that exceeds existing design requirements for DOT-111 tank cars. (R-12-5) Require that all bottom outlet valves used on newly manufactured and existing non-pressure tank cars are designed to remain closed during accidents in which the valve and operating handle are subjected to impact forces. (R-12-6) Require that all newly manufactured and existing tank cars authorized for the transportation of hazardous materials have center sill or draft sill attachment designs that conform to the revised Association of American Railroads’ design requirements adopted as a result of Safety Recommendation R-12-9. (R-12-7) With the assistance of the Federal Railroad Administration, require that railroads immediately provide to emergency responders accurate, real-time information regarding the identity and location of all hazardous materials on a train. (R-07-4) (Reiterated) Recent accidents, such as the July 6, 2013, train accident in Lac-Mégantic, Quebec, Canada, which resulted in 47 fatalities and the destruction of the town center, illustrate the danger posed to the public when transporting flammable liquids under the existing regulations that govern the transportation of hazardous materials in railroad tank cars. This is particularly concerning given that, according to the Federal Railroad Administration (FRA), from 2005 through 2012, crude oil traffic by railroad has increased by a factor of 37, with more than 266,000 car loads in 2012. Ethanol traffic increased by a factor of 4.4 from 2005 to 2011, with about 342,000 car loads per year. Thus, crude oil and ethanol represent the vast majority of hazardous materials shipments on railroads today and deserve special consideration. Train cars containing flammable liquids, such as DOT-111 tank cars, are assembled in many groups of three or more in the train consist. A more significant hazard results when the entire train is assembled with only crude oil, as was the case in the Lac-Mégantic, Quebec, train derailment, or ethanol tank cars. These so-called “unit trains” are becoming the preferred configuration for moving crude oil by railroad from the production field to the refinery. Regardless of the train configuration, recent railroad accidents have shown that using DOT-111 tank cars to ship flammable liquids creates an unacceptable public risk. In light of the Quebec accident and most recently, the derailment of DOT-111 tank cars in Aliceville, Alabama, on November 7, 2013, that resulted in a large crude oil release and fire, the NTSB urges PHMSA to take immediate action to require a safer package for transporting flammable hazardous materials by rail. In the Cherry Valley, Illinois, accident report, the NTSB noted that DOT-111 tank cars have a high incidence of tank failures during accidents, and cited several accident investigations dating back to 1991. Since the NTSB issued its report, additional tank car derailment accidents with catastrophic outcomes further demonstrate that improved requirements for rail transportation of flammable liquids is warranted and should be based on sound risk assessment methodology. The NTSB also believes that an aggressive retrofit and/or phase-out program is necessary for existing DOT-111 tank cars to improve rail transportation safety. The NTSB has classified the Cherry Valley, Illinois, safety recommendations as “Open?Acceptable Response” pending completion of the PHMSA rulemaking that satisfies these safety recommendations. The urgency of acting on the NTSB safety recommendations was not fully recognized until the severity of the Lac-Mégantic accident was realized. Accordingly, with the unprecedented volume of flammable liquids currently in rail commerce, the NTSB urges PHMSA to make this rulemaking a priority to avoid future catastrophic accidents. The NTSB has reviewed the Association of American Railroads (AAR) November 14, 2013, comments to the ANPRM docket, filed jointly with the American Shortline and Regional Railroad Association, that support improving tank car design standards, and the NTSB is encouraged that these two organizations recognize the current regulations governing construction of the DOT-111 tank car are insufficient for ensuring the safe transportation of flammable liquids. The NTSB also is encouraged that the AAR has reconsidered its initial petition, P-1577, and now advocates more comprehensive safety improvements well beyond those it initially proposed to improve accident performance of DOT-111 tank cars. Regarding Safety Recommendation R-07-4, the NTSB continues to investigate accidents where emergency responders did not receive timely and accurate hazard information from railroad operators. Following the November 30, 2012, derailment of a Conrail freight train with release of vinyl chloride in Paulsboro, New Jersey, the NTSB convened an investigative hearing on July 9–10, 2013. Emergency responders testified at the hearing that their response actions were hindered by the lack of timely and accurate train consist information. The availability of a consist document that conveys the identity and location of hazardous materials on a train involved in an accident is critical to executing a safe emergency response. Important safety decisions that rely on timely hazard communications include determining appropriate isolation distances, deciding whether evacuation or shelter-in-place is appropriate, determining appropriate health and safety protocols for responders and rescuers, and deciding appropriate firefighting tactics. The NTSB strongly believes that available technologies can and should be used to supplement the paper-based train consist for improving the dissemination of chemical hazard information to emergency responders. However, we are very disappointed that Safety Recommendation R-07-4 has remained open for more than 5 years. The NTSB is encouraged by the PHMSA Hazardous Materials Automated Cargo Communications for Efficient and Safe Shipments program (HM-ACCESS) and notes that PHMSA has instituted a paperless hazard communication pilot program to evaluate the feasibility and effectiveness of paperless electronic communication systems. Pending completion of the recommended action, the NTSB has classified Safety Recommendation R-07-4 “Open–Acceptable Response.” The NTSB urges PHMSA to promptly move these critical safety initiatives forward by implementing our recommendations and promulgating improved and effective regulations addressing hazardous liquids transportation in the railroad industry. The NTSB appreciates the opportunity to comment on the notice.

From: NTSB
To: PHMSA
Date: 4/23/2013
Response: Notation 8486: On March 11, 2013, the US Chemical Safety and Hazard Investigation Board (CSB) published a request for public comment on a document released on its website titled “Draft Recommendations Evaluation for Public Comment: Fatigue Risk Management Systems (FRMS)” (CSB Evaluation). Subsequently, CSB staff invited the National Transportation Safety Board (NTSB) to share its experiences in investigating transportation accidents in which human fatigue was identified as a safety issue, and related NTSB safety recommendations. The NTSB is an independent federal agency charged with determining the probable cause of transportation accidents and issuing safety recommendations aimed at preventing future accidents. The NTSB has a long history of making recommendations to reduce fatigue and fatigue-related transportation accidents and, since its inception, has issued over 200 recommendations addressing fatigue in the aviation, highway, marine, railroad, and pipeline modes. We are pleased to share our experiences with the CSB. The CSB Evaluation comments on actions taken by the American Petroleum Institute (API) and the United Steelworkers International Union (USW) in response to Recommendation No. 2005-04-I-TX-7, issued by the CSB in 2005 to those organizations. The CSB recommendation was issued as a result of the March 23, 2005, Texas City, Texas, refinery explosion and fire. The portion of the CSB recommendation pertinent to this letter reads as follows: [D]evelop fatigue prevention guidelines for the refining and petrochemical industries that, at a minimum, limit hours and days of work and address shift work…. In April 2010, the API issued an American National Standards Institute-approved Recommended Practice titled Fatigue Risk Management Systems for Personnel in the Refining and Petrochemical Industries, First Edition (RP-755), and an accompanying technical report titled Fatigue Risk Management Systems for Personnel in the Refining and Petrochemical Industries, Scientific and Technical Guide to RP 755. The CSB Evaluation presents the results of a CSB staff review in which the CSB staff determined that RP-755 does not meet the intent of the CSB recommendation in several areas. The NTSB has reviewed RP-755 as well as the CSB Evaluation. With respect to human fatigue, the NTSB has specific experience with the following issues that are discussed in the CSB Evaluation: • The hours-of-service limits described in RP-755, which are more permissive than what is indicated by current scientific knowledge, and the suggestion that voluntary FRMS programs will compensate for the risk from excessive hours and days at work, and • The emphasis of RP-755 on voluntary efforts by industry and its lack of explicit requirements, especially with respect to elements of an effective fatigue management system. With respect to the hours-of-service limits, RP-755 describes “work sets” during normative conditions, which may include 12-hour day shifts or night shifts for 7 consecutive days, with the possibility of an additional “holdover period” beyond the duty day for training or safety meetings. The RP states that the “holdover period should not exceed 2 hours and, where possible, occur at the end of the day shift.” However, the use of the language “should” is not a requirement but is defined by the document as a “recommendation or that which is advised but not required in order to conform to the RP.” Therefore, a worker could, during a normal work set, work shifts of 14 hours or greater in a 24-hour period for several days. RP-755 also states that during planned or unplanned outages, workers may be called on to work 12-hour shifts for up to 14 consecutive days, with as little as 36 hours between 14-day, 12-hour work sets. Holdover periods of up to 2 hours are also allowed during outages. The RP also has provisions for extending work shifts up to 18 hours. In several of its accident investigations, the NTSB has recognized the relationship between long duty days and fatigue, both directly and through their effects on reduced sleep lengths during off-duty periods. For example, in the investigation of the October 2004 Corporate Airlines accident in Kirksville, Missouri, the NTSB determined that the probable cause of the accident was the pilots’ failure to follow established procedures and properly conduct an instrument approach at night, and that fatigue was one factor that contributed to the pilots’ degraded performance. The length of the pilots’ duty day (at the time of the accident, they had been on duty for 14 1/2 hours) was cited along with less-than-optimal overnight rest time, early reporting time for duty, the number of flight legs, and demanding flight conditions, as factors that resulted in the pilots’ fatigue. In the Kirksville report, the NTSB cited research showing that pilots who worked schedules that involved 13 or more hours of duty time had an accident rate that was several times higher than that of pilots working shorter schedules, and that airplane captains who had been awake for more than about 12 hours made significantly more errors than those who had been awake for less than 12 hours. As a result of the Kirksville investigation, the NTSB issued Safety Recommendation A-06-10 to the Federal Aviation Administration (FAA), which stated the following: A-06-10 Modify and simplify the flight crew hours-of-service regulations to take into consideration factors such as length of duty day, starting time, workload, and other factors shown by recent research, scientific evidence, and current industry experience to affect crew alertness. The NTSB reiterated Safety Recommendation A-06-10 in 2008 following its investigation of the April 2007 Pinnacle Airlines accident in Traverse City, Michigan. In that accident, the NTSB determined that the probable cause of the accident was the pilots’ poor decision-making as they prepared to land the airplane. The NTSB stated that “This poor decision-making likely reflected the effects of fatigue produced by a long, demanding duty day and, for the captain, the duties associated with check airman functions.” The pilots had been on duty for more than 14 hours at the time of the accident. The effectiveness of fatigue management is directly related to the availability of work schedules that allow a sufficient period of time between work shifts for the employee to obtain sufficient restorative sleep. The NTSB has investigated several accidents and serious incidents that provided clear and compelling evidence that air traffic controllers were sometimes operating in a state of fatigue because of their work schedules and poorly managed utilization of rest periods between shifts, and that fatigue had contributed to controller errors. Consequently, the NTSB issued Safety Recommendation A-07-30 to the FAA, which stated the following: A-07-30 Work with the National Air Traffic Controllers Association to reduce the potential for controller fatigue by revising controller work-scheduling policies and practices to provide rest periods that are long enough for controllers to obtain sufficient restorative sleep and by modifying shift rotations to minimize disrupted sleep patterns, accumulation of sleep debt, and decreased cognitive performance. The NTSB’s consideration of how long duty days affect fatigue and safety has not been limited to the aviation mode. Recently, in our investigation of the September 2010 collision of two freight trains near Two Harbors, Minnesota, the NTSB concluded that crew fatigue was a contributing factor in train crew errors that led to the collision. The train crewmembers who made the errors had been awake between 13 and 14 hours at the time of the accident, and the accident occurred during the final hour of a 12-hour shift. In its report, the NTSB cited a study showing that 12 hour work shifts have been associated with decrements in alertness and performance, compared to 8-hour shifts. Other studies of commercial drivers have found an exponential increase in crash risk with increasing driving times, especially for driving periods that extend beyond 8 or 9 hours. The NTSB has made numerous recommendations concerning hours of service across the transportation modes. A common theme of those NTSB recommendations has been an emphasis on establishing hours-of-service limits that are scientifically based, that set limits on hours of service, that provide predictable work and rest schedules, and that consider circadian rhythms and human sleep requirements. The second issue discussed in the CSB Evaluation with which the NTSB has experience concerns the lack of explicit requirements regarding essential elements of a fatigue management program. The CSB Evaluation remarks that The use of the word ‘should’ for most elements of a Fatigue Risk Management System (FRMS) in the RP means that they are optional, not required. In what is already a voluntary standard to begin with–employers can choose to conform to them, but they are not required by force of law to do so–‘should’ statements have very little force. The lack of required FRMS elements raises additional concerns because RP-755 states that its hours-of-service limits were “developed in the context of the existence of a comprehensive FRMS” and that “Consistently working at the limits shown is not sustainable and may lead to chronic sleep debt.” Hence, while RP-755 does not require the use of an FRMS, it does ostensibly allow operators to persistently schedule workers at the noted limits. The NTSB has recommended requiring the implementation of fatigue management programs. For example, as a result of its investigation of a June 2009 multivehicle accident near Miami, Oklahoma, in which a truck driver’s fatigue resulted in his failure to react to and avoid colliding with a slowing traffic queue, the NTSB emphasized the importance of comprehensive fatigue management programs. The report described the North American Fatigue Management Program (NAFMP), which is designed to address scheduling policies and practices, fatigue management training, sleep disorder screening and treatment, and fatigue monitoring technologies. In the report, the NTSB stated that “if the NAFMP guidelines remain voluntary—and are used by some carriers but ignored by others—this important safety tool might have only a limited effect in reducing fatigue-related highway accidents.” As a result of its investigation, the NTSB called on the Federal Motor Carrier Safety Administration to implement the following NTSB safety recommendation: H-10-9 Require all motor carriers to adopt a fatigue management program based on the North American Fatigue Management Program guidelines for the management of fatigue in a motor carrier operating environment. The NTSB has also made recommendations in the highway, railroad, and aviation modes to establish ongoing programs to evaluate, report on, and continuously improve fatigue management programs implemented by operators (NTSB Safety Recommendations H-08-14, R 12-007, A-06-11, and A-08-45). I hope that this information about the NTSB’s history of investigating fatigue-related accidents and the recommendations we have issued will be useful as the CSB moves forward with the evaluation of the API and USW responses to the fatigue-related CSB recommendation resulting from the Texas City investigation.

From: NTSB
To: PHMSA
Date: 8/2/2012
Response: The NTSB understands that PHMSA, the FRA, and the failed tank car manufacturer are sponsoring research at the DOT’s Volpe Center on the failed tank car sill design to determine the magnitude and direction of the forces required to reproduce the accident failure and the boundary conditions, such as pinning of the head, at the time of failure. Other tank car designs will also be evaluated to identify deficiencies. Based on the results of this research, PHMSA, the FRA, and the tank car manufacturer will identify and evaluate design modifications to prevent such a failure from recurring. PHMSA indicated that it would provide periodic updates on the progress of the research project and any decisions it makes regarding the establishment of new sill design requirements in the hazardous material regulations. It also plans to update the NTSB about the incorporation of any design requirements adopted by the AAR in response to Safety Recommendation R-12-9. Accordingly, Safety Recommendation R-12-7 is classified OPEN—ACCEPTABLE RESPONSE. Please note that, in order for us to close this recommendation in an acceptable status, PHMSA will need to require design modifications to tank cars that will prevent a recurrence of the design problem involved in the Cherry Valley accident.

From: PHMSA
To: NTSB
Date: 5/30/2012
Response: -From Cynthia L. Quarterman, Administrator: The dynamics of the failure of the tank shell associated with sill attachments that occurred in the Cherry Valley, Illinois, incident is linked to one particular sill design. The FRA, with assistance from PHMSA, is conducting a research project with DOT’s Volpe Center and the manufacturer of the rail tank car that failed. We will evaluate the manufacturer’s sill design to determine the magnitude and direction of the forces required to reproduce the failure and the boundary conditions (e.g., pinning of the head) at the time of failure. Based on the results of the project, PHMSA, the FRA and the tank car manufacturer will identify and evaluate design modifications that will prevent such a failure from reoccurring. Likewise, we plan to extend our evaluation to include other sill designs to determine if there are any deficiencies associated with these designs in protecting the integrity of the tank shell in an accident in which the draft sill is subjected to significant downward deformation. PHMSA will work with the FRA to periodically update the NTSB on the progress of the research project and any decision made regarding the adoption of new sill design requirements into the HMR as well as the incorporation of any design requirements adopted by AAR as a result of Safety Recommendation R-12-9.