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Safety Recommendation Details

Safety Recommendation R-15-016
Synopsis: The National Transportation Safety Board (NTSB) urges the Pipeline and Hazardous Materials Safety Administration (PHMSA) to take action on the safety recommendations issued in this letter. These recommendations are derived from the NTSB’s examination of damaged tank cars following the February 16, 2015, derailment of a CSX Transportation crude oil unit train in Mount Carbon, West Virginia, as well as a review of data collected from accidents that occurred in Gogama, Ontario, on February 14, 2015; Galena, Illinois, on March 5, 2015; and Gogama, Ontario, on March 7, 2015.Theserecommendationsaddressthe retrofitting of thermal protection systems for Department of Transportation (DOT) specification DOT-111 tank cars used to transport Class 3 flammable liquids. Based on the unacceptable performance of bare steel tank cars as evidenced in the four accidents listed above, the NTSB is issuing four safety recommendations to PHMSA.
Recommendation: TO THE PIPELINE AND HAZARDOUS MATERIALS SAFETY ADMINISTRATION: Require an aggressive, intermediate progress milestone schedule, such as a 20percent yearly completion metric over a 5-year implementation period, for the replacement or retrofitting of legacy DOT-111 and CPC-1232 tank cars to appropriate tank car performance standards, that includes equipping these tank cars with jackets, thermal protection, and appropriately sized pressure relief devices. (Urgent)
Original recommendation transmittal letter: PDF
Overall Status: Open - Unacceptable Response
Mode: Railroad
Location: Mount Carbon, WV, United States
Is Reiterated: Yes
Is Hazmat: No
Accident #: DCA15FR005
Accident Reports:
Report #: None
Accident Date: 2/16/2015
Issue Date: 4/6/2015
Date Closed:
Addressee(s) and Addressee Status: PHMSA (Open - Unacceptable Response)
Keyword(s): Hazmat

Safety Recommendation History
From: NTSB
Date: 11/27/2018
Response: R-15-016 Safety Recommendation was reiterated as a result of NTSB Railroad Accident Report, “Derailment and Hazardous Materials Release of Union Pacific Railroad Unit Ethanol Train, Graettinger, Iowa, March 10, 2017.” Report Number RAR-18-02. Adopted on October 30, 2018 and published on November 27, 2018. 2.5.4 DOT-111 Tank Car Fleet Replacement PHMSA final rule HM-251, published on May 8, 2015, established new and safer specification DOT-117 tank car design criteria for nonpressure tank cars transporting flammable liquids, a performance standard DOT-117P, and a retrofit standard DOT-117R to which existing DOT-111 tank cars may be converted (Federal Register, 2015a, 26644). These new specifications were intended to address crashworthiness concerns NTSB raised in earlier investigations that cited poor DOT-111 tank car performance as a critical safety issue. The new specifications addressed NTSB Safety Recommendations R-12-5 and R-12-6 that called for enhanced puncture resistance and fitting and valve protection for tank cars transporting crude oil and ethanol that were issued as a result of the June 19, 2009, derailment of an ethanol unit train in Cherry Valley, Illinois (NTSB 2012). The new specifications also addressed NTSB Urgent Safety Recommendations R-15-14 and R-15-15 that stressed the importance of thermal protection systems for new and existing tank cars in flammable liquids service that were issued following the February 16, 2015, derailment of a crude oil unit train containing CPC-1232 tank cars in Mount Carbon, West Virginia.75 In accordance with final rules HM-251 and HM-251C [as mandated by the Fixing America’s Surface Transportation Act (FAST Act)], the HMR have established commodity-based deadlines for phase-out or retrofitting DOT-111 tank cars in continued flammable liquids service (Federal Register, 2016a, 53935). PHMSA final rule HM-251 is not the first time that the DOT mandated a tank car safety enhancement and retrofit program. The DOT embarked on a similar effort in 1977, when it issued final rule HM-144, requiring that all new and existing specification 112 and 114 tank cars transporting flammable gases be equipped with thermal and tank head protection systems, and coupler restraint systems (Federal Register, 1977, 46306). In response to a 1978 NTSB public hearing on derailments and hazardous materials, the DOT amended the rule to require an accelerated retrofit schedule for existing flammable gas tank cars over a 2.5-year period (Federal Register, 1978a, 30057). The retrofit schedule required fleet owners to retrofit 20 percent of their existing fleets within 6 months, 65 percent by the following year, and their remaining tank cars by the following year. In September 1978, the DOT issued a supplementary final rule to address compliance reporting (Federal Register, 1978, 39792). At that time, the DOT recognized that it was not sufficient to simply mandate the retrofit program because neglect by a tank car owner or owners to establish an adequate pace of retrofit could have resulted in a failure to meet regulatory deadlines. The DOT was concerned that such a failure could have resulted in an accumulation of unequipped cars, which would have been prohibited from use in transportation. The NTSB has the same concerns today regarding the current ethanol fleet of DOT-111 tank cars. Because the ethanol fleet of legacy DOT-111 tank cars constitutes a substantially large percentage of the overall general service tank car fleet, the NTSB is concerned about the potential for critical short-term shortages of DOT-117-compliant tank cars for flammable liquids transportation if tank car owners fail to take adequate measures to assure the phased completion of the retrofits and replacements. Due to the high demand for general service tank cars to transport ethanol and other flammable materials, it is essential that tank car owners make careful plans to assure their fleets are converted in advance of applicable deadlines. The accident tank cars were constructed between 2003 and 2009 and had the least crash-resistant features available for flammable liquids service. These legacy DOT-111 tank cars have the thinnest (7/16-inch thick) tank shells that are usually constructed of non-normalized steel, no head shields or puncture resistance system, no thermal protection system, and too little protection for top and bottom fittings. These shortcomings are responsible for the track record of poor accident performance for DOT-111 tank cars, especially since 2007 following their introduction into widespread use for flammable materials unit trains. Federal regulations place the burden on the shipper to offer the hazardous material in a package that is authorized for transportation. Although safer tank cars such as the DOT-117 are available, Green Plains obtained the accident train tank cars that meet current federal minimum safety standards from seven different leasing companies based on availability and market prices. Since most shippers are not rail car fleet owners and generally obtain tank cars through full service lease terms, they must rely on third-party leasing companies to ensure that replacement tank cars are available before the regulatory deadline for replacing DOT-111 ethanol tank cars by May 1, 2023. None of the tank cars in the accident train consist were constructed to DOT-117 specification requirements. At the time of this accident, three of the seven leasing companies that supplied tank cars used in the accident train had purchased significant numbers of DOT-117 tank cars. However, their rail car leasing fleets consisted predominantly of legacy DOT-111 and CPC-1232 tank cars.76 At the time of this accident, three other leasing companies that supplied tank cars for the accident train had no DOT-117 tank cars in their fleets. Prior to the publication of PHMSA final rule HM-251, the NTSB expressed concern about the lack of intermediate progress milestones for completing tank car modifications or replacements and the lack of transparency to hold the rail car owners accountable for progress toward implementing safer tank car fleets. This issue was addressed following the investigation of the Mount Carbon, West Virginia, accident with safety recommendations to PHMSA.77 Require an aggressive, intermediate progress milestone schedule, such as a 20 percent yearly completion metric over a 5-year implementation period, for the replacement or retrofitting of legacy DOT-111 and CPC-1232 tank cars to appropriate tank car performance standards, that includes equipping these tank cars with jackets, thermal protection, and appropriately sized pressure relief devices. (R-15-16) Safety Recommendation R-15-16 is currently classified Open—Unacceptable Response because PHMSA has not established a clear set of intermediate metrics that it could use to evaluate the safety improvement progress. The second recommendation, Safety Recommendation R-15-17, requested 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 as recommended in safety recommendation R-15-16. (R-15-17) Safety Recommendation R-15-17 is classified Open—Acceptable Response because PHMSA, collaborating with its stakeholders, entered into an agreement with the Bureau of Transportation Statistics (BTS) to collect and report data about progress made in modifying or replacing DOT-111 tank cars. To encourage compliance with DOT-111 replacement deadlines, Section 7308 of the FAST Act required the secretary of transportation to implement a reporting mechanism to monitor industry-wide progress toward modifying tank cars and to report the aggregate results of its tank car data survey annually to Congress. On September 22, 2017, the BTS submitted its first report to Congress detailing the fleet composition of rail tank cars transporting flammable liquids (BTS 2017). The BTS reported that as of the end of 2016, about 9 percent of the 81,000 tank cars used to transport Class 3 flammable liquids met new safety requirements. At that time, most of the flammable liquids fleet (53 percent) still consisted of nonjacketed DOT-111 tank cars, such as the tank cars that were involved in this accident. The number of nonjacketed DOT-111 tank cars used to transport ethanol has remained steady between 2014 and 2016 at about 26,000 to 28,000. However, during 2016, the BTS reported some progress with about 1,700 new DOT-117 and 1,200 retrofitted DOT-117R tank cars added to the ethanol fleet. However, the slow pace of ethanol fleet tank car conversions has prompted concern by the AAR and others in the industry about the availability of DOT-117 tank cars to service the flammable liquids fleet in years to come (Fronczak 2017). PHMSA stated in the U.S. Department of Transportation’s Status of Actions Addressing the Safety Issue Areas on the National Transportation Safety Board’s Most Wanted List: A Report to Congress and the National Transportation Safety Board that it is working with the rail industry and tank car facilities to develop reporting mechanisms to monitor tank car replacement progress and provide Congress with an annual written report (DOT 2017). PHMSA stated it believes the transparency of the BTS report will help encourage industry to replace tank cars at a rate ahead of scheduled deadlines. However, in contrast to the earlier pressure tank car replacement regime mentioned above, the current regulatory scheme that responds to Section 7308(e) of the FAST Act requires DOT to redact tank car owners’ identities from progress reports to Congress. It requires DOT to report data in industry-wide totals and to treat company-specific information as confidential business information; therefore, shielding individual fleet owners from public scrutiny of their tank car replacement progress, or lack of progress. Therefore, the report to Congress does not offer complete transparency. Unlike the current regulatory system of assured anonymity and voluntary compliance that lacks targeted milestones, DOT chose to remedy potential failure of the earlier program in 1978 when it tasked FRA with closely monitoring the manner in which tank car owners complied with the deadlines. Thus, the 1978 rule required specification 112 and 114 tank car owners to file quarterly progress reports with the FRA, identifying the total number of tank car retrofits accomplished, as well as a declaration of intent concerning the remaining tank cars in their respective fleets. DOT stated that in the event any owner failed to establish a program leading to the timely completion of the retrofit tasks, the FRA could have instituted a compliance order or could have taken appropriate legal action under the provisions of 49 CFR Part 209, “Railroad Safety Enforcement Procedures.” The flammable gas tank car retrofit program was completed in 1980, nearly 1 year earlier than originally anticipated, and the NTSB noted as a result, the frequency and severity of accidents with these tank cars had been significantly reduced.78 In its most recent quarterly report to the AAR Tank Car Committee in May 2018, the AAR stated, “Forty-three percent of the cars used to ship ethanol during the 1st quarter of 2018 were built since 2011 to new standards vs. less than 2 percent in 2013 [that were built after 2011 and met the new standards].” In September 2018, the BTS sent its second report to Congress, Fleet Composition of Rail Tank Cars Carrying Flammable Liquids: 2018 Report. In this report, the BTS reported that nearly 20 percent of the tank cars used to carry Class 3 flammable liquids in 2017 met the new DOT-117 safety requirements—a significant increase from the 2 percent in 2015. The BTS further reported that nonjacketed DOT-111 tank cars, while carrying the largest share of flammable liquids, have decreased by 31 percent between 2014 and 2017. Furthermore, the number of both new and retrofit DOT-117 tank cars used in ethanol service more than doubled between 2016 and 2017 to over 6,000 tank cars (BTS 2018). Newly available AAR flammable liquids fleet utilization figures indicate there was remarkable progress made in replacing DOT-111 cars to transport ethanol in 2017 and also during the first quarter of 2018. According to the AAR, almost 11,000 DOT-117 tank cars were used during the first quarter of 2018 to transport ethanol, while the number of DOT-111 tank cars used to transport ethanol dropped by the same amount between 2016 and 2018. Despite recent tank car replacement progress, BTS and AAR fleet statistics indicate that still nearly one-half of the overall fleet of tank cars carrying flammable liquids were nonjacketed DOT-111, and most of these were used to transport ethanol. However, the NTSB concludes that since PHMSA has not established a clear set of intermediate metrics for evaluating tank car conversion and replacements, achievement of the deadlines may be overly reliant on future market and economic conditions. Therefore, NTSB reiterates Safety Recommendation R-15-16, which requests tank car retrofitting and replacement progress milestones.

Date: 11/9/2016
Response: -From Marie Therese Dominguez, Administrator: In your letter of July 12, 2016, NTSB urged PHMSA to extend the requirement for thermal protection systems to all tank cars in Class 3 flammable liquids service, regardless of the type of train operation. Furthermore, NTSB urged PHMSA to issue thermal protection regulations in accordance with the FAST Act that would require thermal blankets capable of providing protection from pool fires and torch fires consistent with § 179 .18(c) of the HMR. The NTSB also noted, in accordance with Section 7305 of the FAST Act, that each tank car built to meet the DOT Specification 117 (DOT -117) and each non-jacketed tank car modified to meet DOT-117R must be equipped with a thermal blanket with at least V2-inch-thick material. The NTSB further voiced its concern regarding the current pace of the retrofit and replacement of DOT-111 tank cars and urged PHMSA to establish a clear set of intermediate metrics to better evaluate the safety improvement progress. On August 15,2016, PHMSA published a final rule titled, "Hazardous Materials: FAST Act Requirements for Flammable Liquids and Rail Tank Cars," in the Federal Register [81 FR 53 93 5]. The final rule codifies certain mandates and minimum requirements of the FAST Act. Specifically, the final rule codifies the following: (1) a revised phase-out schedule for all ·. DOT -111 tank cars used to transport Class 3 flammable liquids broken into categories of unrefined petroleum products (e.g., petroleum crude oil), ethanol, and "other" Class 3 flammable liquids; (2) the mandate that each tank car built to DOT -117 and each non-jacketed tank car retrofitted to DOT -117R be equipped with a thermal protection blanket that is at least ½ inch thick and meets existing thermal protection standards; and (3) the minimum requirements for top fittings protection on tank cars retrofitted to DOT -117R. PHMSA believes the FAST Act and the conforming final rule satisfy the intent of Safety Recommendations R-15-14 through R-15-17. The FAST Act limits PHMSA's ability to withdraw, change, or revise the mandated amendments. While the phase out schedule for DOT -111 tank cars may not be as aggressive as NTSB desires, the deadlines represent the absolute last moment to meet the new standards. We encourage industry to phase out these tank cars ahead of the scheduled deadlines. Section 7308 of the FAST Act further requires the collection and reporting of two data sets related to the retrofit and replacement of tank cars used in the flammable liquid service fleet. The first data set is retrospective in nature and requires DOT to collect information on the number of tank cars modified to meet the DOT -117R; the number of tank cars built to meet the DOT -117; and the number of tank cars used or likely to be used to transport Class 3 flammable liquids that have not been modified. In addition, the FAST Act requires collection of a second data set pertaining to future industry capacity projections. Specifically, DOT is required to conduct a survey of rail tank car facilities to determine statistically-valid estimates of the number of tank cars those facilities expect to process to meet the DOT -117R or DOT -117 demand in a given year. The DOT is working with rail industry and tank car facilities, respectively, to develop reporting mechanisms to monitor progress. AAR has agreed to cooperate and is currently compiling retrospective data to be provided to DOT. In accordance with Section 7308(t) of the FAST Act, DOT will provide to Congress an annual, written report covering both data sets.

From: NTSB
Date: 7/12/2016
Response: Although we would have preferred a more aggressive schedule than the 10 years for full implementation that HM-251 provides, we understand that your deadlines were based on an analysis of shop capacity and logistics and are closely aligned with those of Transport Canada. The FAST Act further codifies a commodity-based implementation schedule that is substantially similar to that which was originally contained in HM-251, with the requirement that tank cars used for other flammable materials must be replaced or retrofitted by 2029. The NTSB continues to stress the need for a much timelier and documented replacement of the less-safe tank cars. In the absence of mandated implementation milestones, the scheduling decisions for upgrading the existing fleet of DOT-111 and CPC-1232 tank cars to safer tank car designs is left entirely to fleet owners, and may be driven by market factor influences, not safety improvements. The HM-251 rule and the FAST Act established end-stage completion dates for removing existing DOT-111 and CPC-1232 cars transporting crude oil and ethanol from service by 2025, and for removing tank cars transporting all other Class 3 commodities from service by May 1, 2029. Furthermore, the FAST Act authorizes the DOT secretary to extend the deadlines for up to 2 years if the secretary determines that insufficient shop capacity is available for retrofitting tank cars. The end result could be that many existing hazardous materials tank cars that are prone to catastrophic failure in a derailment could remain in service for up to 15 years. The intent of the recommendation is to replace the existing, less-safe tank car fleet as quickly as possible. To date, the industry has progressed very slowly with the existing fleet retrofit and replacement work, with only 223 tank cars retrofitted to DOT-117R specifications and about 7,090 new DOT-117 tank cars entered into service. Accordingly, Safety Recommendation R-15-16 is classified OPEN—UNACCEPTABLE RESPONSE until PHMSA establishes a clear set of intermediate metrics that it can use to evaluate the safety improvement progress.

Date: 5/4/2015
Response: -From Timothy P. Butters, Deputy Administrator: This letter responds to the National Transportation Safety Board’s (NTSB) April 3, 2015, letter urging the Pipeline and Hazardous Materials Safety Administration (PHMSA) to take action on new Safety Recommendations concerning rail transportation of Class 3 flammable liquids. These new Safety Recommendations, R-15-14 through R-15-17, resulted from the NTSB’s examination of damaged tank cars following the February 16, 2015, derailment of a CSX Transportation crude oil unit train in Mount Carbon, West Virginia, as well as a review of data collected from several other crude oil unit train accidents occurring in the same timeframe. These Safety Recommendations address the retrofit of Specification DOT-111 tank cars with thermal protection systems that are used to transport Class 3 flammable liquids (hereafter referred to as “flammable liquid”). We thank the NTSB for its vigilance on this transportation safety issue and its continued investigative efforts to improve rail transportation safety for crude oil, ethanol, and other flammable liquids. We share your commitment to enhancing the safety of rail transportation, and are pleased to inform you that Secretary Anthony R. Foxx has signed and announced a final rule entitled “Hazardous Materials: Enhanced Tank Car Standards and Operational Controls for High-Hazard Flammable Trains” (HM-251). Pending publication of the final rule in the Federal Register, we posted the signed version at our website homepage for public viewing. This rule focuses on prevention, mitigation, and response, to manage and reduce the risk posed by the transportation of flammable liquids by rail tank car. Through tremendous collaborative efforts with the Federal Railroad Administration (FRA), we established a comprehensive solution designed to reduce the probability and minimize the consequences of an accident. We have adopted risk mitigation requirements that address braking, classification, operating speeds, and routing to reduce the probability of accidents. Finally, we adopted enhanced design and performance standards for rail tank cars in flammable liquid service to minimize the consequence of an accident. The required safety measures and the timeline for phase-out and retrofit of legacy tank cars used in high-hazard flammable train (HHFT)a service will strike a balance between the safety needs of rail transportation of flammable liquids and the economic viability of the rail industry. Upon consideration of shop capacity, the comments received on the Notice of Proposed Rulemaking (NPRM), and the potential impacts associated with the retrofit schedule, PHMSA recognizes the need to upgrade the rail car fleet, but finds that a targeted phase-out of the DOT-111 tank cars is the most prudent and protective approach. We concur that replacing or retrofitting of “legacy” DOT-111 and CPC-1232 tank cars should follow an “aggressive schedule.” PHMSA used a risk-based data analysis with stakeholder input to develop an implementation timeline that is commensurate with the safety risks introduced by the different tank car types and flammable liquids combinations. We adjusted the retrofit schedule to accommodate varying deadlines, and what we believe will effectively incorporate “intermediate progress milestone[s].” This assures the greatest amount of risk reduction in the shortest amount of time feasible. We target the highest risk combination of tank car types and flammable liquid service (i.e., non-jacketed DOT-111 tank cars in PG I service) first, and impose the shortest implementation period on this segment of the tank car fleet and service by January 1, 2017 and January 1, 2018, respectively. PHMSA's implementation timeline addresses the risks associated with varying tank car type and the characteristics of the flammable liquids according to its Packing Group (PG) assignment. Regarding tank car types, we have categorized the tank car types as follows: 1) Non-jacketed DOT-111s; 2) Jacketed DOT-111s; 3) Non-jacketed CPC-1232s; and 4) Jacketed CPC-1232s. Under the final rule, both new and existing tank cars used in flammable liquid service as part of an HHFT must be equipped with jackets, thermal protection systems, and upgraded PRDs. New tank cars must be constructed to enhanced design and performance standards starting October 1, 2015. The existing fleet must be retrofitted to include a thermal protection system and jacket according to a risk-based implementation timeline that prioritizes retrofit of higher risk tank car types and higher risk flammable liquids; or be placed out of this service. This timeline is reflected in Table 1 below. Table 1. Timeline for the Retrofit of Affected Tank Cars for Use in U.S. HHFTs Tank Car Type / Service Retrofit Deadline Non Jacketed DOT-111 tank cars in PG I service (January 1, 2017*) January 1, 2018 Jacketed DOT-111 tank cars in PG I service March 1, 2018 Non-Jacketed CPC-1232 tank cars in PG I service April 1, 2020 Non Jacketed DOT-111 tank cars in PG II service May 1, 2023 Jacketed DOT-111 tank cars in PG II service May 1, 2023 Non-Jacketed CPC-1232 tank cars in PG II service July 1, 2023 Jacketed CPC-1232 tank cars in PG I and PG II service** and all remaining tank cars carrying PG III materials in an HHFT (pressure relief valve and valve handles). May 1, 2025 The January 1, 2017, deadline triggers a reporting requirement for those entities that have not retrofitted all of their fleet as required. The report to DOT must include the number of tank cars they own or lease that have been retrofitted, and the number of those that have not yet been retrofitted. Conversely, the lowest risk tank car type (i.e., the jacketed CPC-1232), and tank cars carrying PG III flammable liquid material, will undergo retrofitting in conformance with the least aggressive deadline (May 1, 2025). Other tank cars and flammable liquid services are addressed by intermediate milestones as shown in Table 1. PHMSA and FRA have worked with Transport Canada to harmonize our respective timelines As a result; all tiers except for the first tier, of the retrofit schedule have been harmonized. The year 2025 final deadline signals a total implementation period of 10 years; however, we believe our targeted approach to address the greatest risks posed by rail transport of flammable liquid in a shorter period of time satisfies the intent of Safety Recommendation R-15-16 (see Table 1). Notably, the entire fleet of the highest risk tank car type (i.e., non-jacketed or “legacy” DOT-111s in PG I service) will be removed from service or be retrofitted in less than 5 years and all PG I service with these tank cars in HHFTs will cease in 5 years. Further, we fully expect the majority of tank cars in the last, lowest risk grouping (i.e., jacketed CPC-1232 tank cars and all remaining tank cars carrying PG III materials), will be retrofitted markedly in advance of the 2025 deadline because of existing tank car requalification and maintenance scheduling. Finally, we intend to collaborate with various stakeholders to develop an additional reporting mechanism to report the progress made in retrofitting or replacing tank car types in flammable liquid service used as part of a HHFT. We further note that PHMSA and FRA are collaborating with different stakeholders, including Transport Canada and the Association of American Railroads (AAR), to further address this issue. The industry’s achievement of other important milestones in the implementation timeline should be monitored and evaluated in some form. As a possible avenue for an additional reporting mechanism, at the AAR Tank Car Committee Meeting held in April 2015, Transport Canada, with PHMSA and FRA’s support, requested the AAR modify the rail industry’s Universal Machine Language Equipment Register (UMLER) System to include an appropriate reporting mechanism. Modifying UMLER in such a fashion should yield a variety of important metrics that could then be used to assess and report on the progress made in retrofitting or replacing the population of tank cars subject to the thermal protection system requirements. We will update the NTSB on any future progress with regard to a publicly available reporting mechanism.