NTSB Investigations of Rail Tank Car Accidents. Paul L. Stancil and Muhamed El-Zoghbi Hazardous Materials Accident Investigators May 30, 2015

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1 NTSB Investigations of Rail Tank Car Accidents Paul L. Stancil and Muhamed El-Zoghbi Hazardous Materials Accident Investigators May 30,

2 Outline Overview of NTSB and processes Rail Hazmat Safety Issues Rail Tank Car Accident Performance Planning, Preparedness, and Management of Hazardous Materials Accidents 2

3 NTSB 3

4 Safety Board History First created in 1967 as an independent agency within the US DOT Independent Safety Board Act of 1974 Fully independent agency Investigate transportation accidents Determine probable cause Develop safety recommendations Aviation Disaster Family Assistance 49 CFR Parts

5 Board Members 5 Board Members Christopher A. Hart, Chairman Bella Dinh-Zarr, Vice Chairman Robert L. Sumwalt Earl F. Weener, Ph.D. vacancy Nominated by the President, confirmed by the Senate Board Members are not investigators 5

6 NTSB Mission Independent, fact based investigations Single focus is safety Objective is to determine probable cause Safety recommendations and advocacy 6

7 The True Cause of an Accident 7

8 What the NTSB is Not It is not a regulatory agency Not an emergency response agency Does not issue fines and penalties Does not assign fault or blame Is not part of the Department of Transportation 8

9 Investigative Offices Office of Aviation Safety 9

10 Investigative Offices Office of Highway Safety 10

11 Investigative Offices Office of Marine Safety 11

12 Office of Railroad, Pipeline and Hazardous Materials Investigations Railroad Accidents 12

13 Office of Railroad, Pipeline and Hazardous Materials Investigations Pipeline Accidents 13

14 Office of Railroad, Pipeline and Hazardous Materials Investigations Hazardous Materials Investigations Aviation Highway Marine Railroad Pipeline 14

15 NTSB Investigations 15

16 Accident Investigation Accident investigation is the primary tool used by the Safety Board to develop recommendations for safety improvements 16

17 Statutory Requirement to Investigate Railroad Accidents Independent Safety Board Act of 1974 Railroad accidents that involve: Fatality Substantial Property Damage Passenger Train 17

18 Priority of Board Investigations NTSB investigations have priority over investigations by other federal agencies Other federal agencies (FRA, EPA) may conduct concurrent investigations Exception: Criminal investigations under control of the FBI 18

19 Railroad Accident Investigation 19

20 Composition of Investigation Teams The on-scene investigative team typically consists of an Investigator in Charge (IIC) and groups of the following disciplines: Mechanical Operations Signal Track Human Performance Survival Factors 20

21 Composition of Investigation Teams Other specialized groups are formed as necessary, including the following: Hazardous Materials Metallurgical Event Recorder Video Recorder Fire/Explosion Environmental Response 21

22 The Party System NTSB leverages its resources by designating parties to its investigations 22

23 The Party System NTSB regulations state that parties shall be limited to those persons, government agencies, companies, and associations whose employees, functions, activities, or products were involved in the accident or incident and who can provide suitable qualified technical personnel actively to assist in the investigation. 23

24 The Party System Typical Party Members: Railroad Federal Railroad Administration Labor organizations State safety investigators Emergency responders Local municipalities Equipment manufacturers 24

25 Groups work under the direction of the Group Chairmen The Party System Groups remain intact for the duration of the investigation All parties do not participate in all groups 25

26 Limitations on Party Participation Groups not permitted to participate in any phase of the investigation include: Public affairs News media Attorneys Claims Agents 26

27 Limitations on Party Participation Parties are prohibited from speaking about the investigative findings with the news media or the public No independent investigations by parties No information is withheld from the NTSB 27

28 Investigative Process Organizational meeting Daily progress meetings On-scene close-out meeting Laboratory examination Technical review meeting 28

29 Board Members On Scene Provide factual information to the families of victims and the news media regarding the progress and findings of the investigation Brief local, state, and federal elected officials about the progress of the investigation 29

30 Investigation Support Public Information Government Affairs Transportation Disaster Assistance General Counsel 30

31 Research and Engineering The Office of Research and Engineering provides technical support to investigations 31

32 Research and Engineering The Materials Lab performs failure analysis of components 32

33 Research and Engineering The Recorders Lab recovers and analyzes data from event recorders 33

34 Investigative Hearings To gather additional factual information about an accident in a public forum 34

35 Investigative Hearings Board of Inquiry Board Members and senior NTSB staff Technical Panel NTSB technical staff that are conducting the investigation Party Members Persons and organizations that can provide special or technical knowledge 35

36 Final Accident Report Draft report is prepared by staff Draft report is presented to the Board Members at a public meeting Board Members vote to adopt the report as presented or with modification Report is generally prepared within 12 to 24 months 36

37 Other NTSB Safety Programs Special Investigations Focuses on a specific safety issue May involve multiple accidents Determines the facts, conditions, and circumstances Does not always determine the probable cause 37

38 Other NTSB Safety Programs Safety Studies Evaluate the effectiveness of Federal, State, local, and industry transportation safety programs Examine policy issues, program coverage, and management effectiveness 38

39 Questions? 39

40 Hazardous Materials on Rail Railroads are integral part of hazardous materials transportation 28.5% of total ton-miles of all hazardous materials (2007)* Average miles per shipment miles (2012) Total Loaded Tank Car Originations in 2013**: All Hazardous Commodities:1,611,325 TIH Commodities: 56,049 * U.S. Bureau of Transportation Statistics (BTS)/U.S. Census Bureau s Commodity Flow Survey (2007 & 2012) ** Association of American Railroads Annual Report of Hazardous Materials Transported By Rail (2013) 40

41 Crude Oil and Ethanol Rail Carloads AAR 2013: Moving Crude Oil by Rail ; Railroads and Ethanol Ethanol carloads estimated from RFA data for 2012 and 2013 Crude Oil Thousands of Carloads Ethanol 41

42 Significant Crude Oil and Ethanol Accidents October 2006 New Brighton, PA August 2008 Luther, OK October 2011 Tiskilwa, IL E C E June 2009 Cherry Valley, IL E E E October 2007 Painesville, OH February 2011 Arcadia, OH 42 E Ethanol C Crude Oil

43 Significant Crude Oil and Ethanol Accidents March 2013 Parkers Prairie, MN July 2013 Lac-Mégantic, QC July 2012 Columbus, OH E C C C C December 2013 Casselton, ND January 2014 Plaster Rock, NB 2012 August 2012 Plevna, MT E 2013 April 2013 Bremner, ON C C 2014 C C C April 2014 Lynchburg, VA February 2014 Vandergrift, PA November 2013 Aliceville, AL January 2014 New Augusta, MS 43 E Ethanol C Crude Oil

44 Significant Crude Oil and Ethanol Accidents February 2015 Waupeton, IA March 2015 Gogama-2, ON March 2015 Galena, IL E C C 2015 C C February 2015 Gogama-1, ON February 2015 Mt. Carbon, WV 44 E Ethanol C Crude Oil

45 Crude Oil and Ethanol Accidents 23 significant accidents since crude oil 8 ethanol 48 fatalities 405 DOT-111 tank cars derailed 4 million* gallons crude oil released 2.1 million gallons ethanol released Fires and environmental damage *estimated 45

46 Rail Hazmat Safety Issues Tank car accident performance Puncture resistance Thermal resistance Fittings protection Emergency response Community awareness and emergency response planning First responder notification - Hazcom Training - HAZWOPER 46

47 Rail Hazmat Safety Issues Railroad operations Route planning and route selection Hazardous materials classification Speed restrictions Track inspection frequency Enhanced braking Oil spill planning 47

48 Tank Car Accident Performance With unit trains transporting large numbers of crude oil and ethanol flammable liquid tank cars Multiple investigations found that general service tank cars (DOT-111) breach at high frequency in derailments Potential for future severe train accidents is increasing, raising likelihood of highconsequence events 48

49 Flammable Liquids Tank Car Safety Equipment Courtesy the Greenbrier Companies, Inc. 49

50 Head and Shell Puncture Resistance Existing DOT-111s do not have head shields Bare Head Tank Material 7/16 inch DOT-111 TANK CAR 50

51 Head Puncture Lac-Mégantic, QC, 2013 Bottom Top Casselton, ND,

52 Shell Cracking and Tearing Crack Cherry Valley, IL, 2009 Lac-Mégantic, QC,

53 53

54 Thermal Resistance No requirement for tank jacket No requirement thermal protection DOT-111 TANK CAR 54

55 Thermal Failure and Fireball Release No tank jacket No thermal protection Insufficient pressure relief capacity Mount Carbon, WV, 2015 Columbus, OH,

56 Casselton, ND,

57 Thermal Failure and Fireball Release Video Columbus Ohio derailment July 11, 2012 Tank car rupture in pool fire. 57

58 Mount Carbon, WV, February 16, punctured cars (red) 13 cars with thermal tears (green) 58

59 Boomer Mount Carbon Accident Location Kanawha River N 59

60 Energetic Ruptures Arcadia, OH,

61 Top and Bottom Fittings Protection Top Fittings DOT-111 TANK CAR Bottom Fittings 61

62 Top and Bottom Fittings Vulnerability Cherry Valley, IL, 2009 Fittings not adequately protected Casselton, ND, 2013 Open Bottom Outlet Top Fittings Damage Damaged Operating Handle 62

63 Top Fittings Failures Pressure Relief Device Manway Hinge Breach Lac-Mégantic, QC, 2013 Unfastened Swing Bolts Tiskilwa, IL,

64 Tank Car Safety Recommendations R-12-5: Tank head and shell punctureresistance systems and top fittings protection R-12-6: Bottom outlet valve closure R-12-7 and -9: Draft sill attachments with appropriate weld separation R-07-2 and -4: (reiterated) Hazard communications for emergency responders 64

65 Tank Car Safety Recommendations R-15-14: Thermal protection systems for flammable liquids tank cars R-15-15: Appropriately sized pressure relief devices R-15-16: Progress schedule for retrofit and replacement of existing tank cars R-15-17: Public reporting of retrofitting progress 65

66 Other Safety Recommendations Crude Oil and Flammable Materials R-14-1 and -4: Expand route planning and selection to key trains transporting flammable liquids R-14-2 and -5: Comprehensive oil spill response plans for worst case discharges R-14-3: Audit safety and security plans R-14-6: Sufficient hazardous materials testing and classification 66

67 Emergency Response Issues NTSB Investigations continue to find issues in the following areas: Community preparation and readiness for large scale hazmat events Sharing of Hazardous materials commodity information Railroad response plans and resources 67

68 Community Awareness Programs and Emergency Response Planning Emergency responders and community unfamiliar with hazardous materials routinely transported through their jurisdictions Railroad outreach is voluntary TRANSportation Community Awareness and Emergency Response (TRANSCAER) Independent outreach initiatives Communities unprepared for hazardous materials transiting their neighborhoods 68

69 Community Awareness Programs and Emergency Response Planning Many Local Emergency Planning Committees (LEPC) and responders do not request commodity flow reports How to request them? AAR Circular OT-55 Railroad provides list of top 25 commodities Commodity flow data needed to conduct capabilities and needs assessment 69

70 Community Awareness Programs and Emergency Response Planning Fixed facility threshold planning quantities often lower than quantities transported by rail Chlorine Fixed facility: 100 lbs (one cylinder) - Planning required Rail: tank car (180,000 lbs) - No planning required 180,000 lbs 100 lbs 70

71 Railroad Spill Response Plans Generally, railroads do not have response plan requirements similar to other modes of transportation Oil Spill Response Plan is required Regulatory requirements are deficient Not as comprehensive as marine or pipeline 71

72 First Responder Notification Railroad must immediately provide train consist (shipping papers) Must be available to responders at all times Must be accurate Carried by train crew Train consists needed to identify, locate, and secure hazardous materials 72

73 Hazardous Waste Operations and Emergency Response (HAZWOPER) HAZWOPER training and knowledge required Uncontrolled hazardous materials releases, OSHA standard, 29 CFR , requires: Site assessment Appropriate emergency operations Personal protective equipment 73

74 ½ mile Breached Tank Car Initial Command Post 50 yards Potential Recommended Initial Evacuation Areas (Weather-dependent) 74

75 Tank Car 10: DOT-105 Vinyl Chloride Punctured N 75

76 Mantua Creek Swing span 56 ft N 76 Paulsboro Moveable Bridge

77 Mantua Creek N Paulsboro Moveable Bridge 77

78 Slide Lock Operation Slide lock (unlocked) Slide lock (unlocked) West fixed rails Moveable span running rails East fixed rails Slide lock (unlocked) Slide lock (unlocked) 78

79 Slide Lock Operation Moveable span running rail Slide lock (locked) Proximity sensor Fixed rail 79

80 East end November 29, about 3:00 a.m. Gap Mantua Creek N 80

81 November 29, about 11:00 p.m. East end Mantua Creek Slide locks unlocked West end N Slide locks partially engaged 81

82 November 30, :52 a.m. Mantua Creek N 82

83 November 30, :02 a.m. Mantua Creek Punctured tank car 83

84 Punctured Tank Car 37 inches 84

85 Safety Recommendations R and 22 Train crews to provide consists and emergency response information to ER officials R Provide LEPC and SERC with commodity flow data and assist with EOPs R-14-15, 20 and 24 Address shortcomings of the Rail Corridor Risk Management System tool R and 23 - Emergency response information consistent with ERG R Implement public education system for communities along hazmat routes 85

86 Safety Recommendations R and 25 - Audit route short line and regional railroads to ensure route risk assessments are being performed R-14-26, 27, and 30 IAFC, NVFC, and NJ Fire Services notify membership about the circumstances of the Paulsboro accident and incorporate lessons learned into training curricula R NJSP ensure communities base EOPs on hazard analysis and risk assessments Reiterated R to require railroads to provide emergency responders with information about identity and location of hazmat on a train 86

87 For Further Information Accident reports at Mount Carbon, WV DCA15FR005 Lynchburg, VA DCA14FR008 Casselton, ND DCA14MR004 Lac-Megantic, QC DCA13SR006 Columbus, OH RAB14-08 Paulsboro, NJ RAR14-01 Tiskilwa, IL RAB Cherry Valley, IL RAR12-01 Anding, MS RAR

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