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NTSB investigators Ruben Payan (left) and Paul Stancil survey the scene of the Aug. 2, 2017, Hyndman, Pennsylvania, train derailment in this photo taken Aug. 4, 2017. © NTSB

WASHINGTON (Dec. 10, 2020) — The National Transportation Safety Board issued Rail Accident Report 20/04 Thursday for its investigation of the Aug. 2, 2017, CSX Transportation, Inc. freight train derailment and release of hazardous materials near Hyndman, Pennsylvania.
No injuries were reported in connection with the derailment of 33 of 178 rail cars but three homes were damaged and about 1,000 residents were within the 1-mile radius evacuation zone. CSX estimated damages at $1.8M.
The accident train consisted of five locomotives and 178 cars, 128 of which were loaded, and 50 rail cars were empty.
NTSB investigators determined the probable cause of the derailment was the inappropriate use of hand brakes on empty rail cars to control train speed, and the placement of blocks of empty rail cars at the front of the train consist. Investigators also determined CSX operating practices contributed to the derailment.
Safety issues addressed in the investigation include:

  • CSX operational practices for building train consists that allowed for excessive longitudinal and lateral forces to be exerted on empty cars
  • Use of hand brakes to control train movement
  • Assessment and response to fires involving jacketed rail tank cars

Based on its investigation the NTSB issued a total of six safety recommendations, including one to the Federal Railroad Administration, three to CSX, one to the Association of American Railroads and one to the Security and Emergency Response Training Center. The recommendations seek:

  • Guidance for railroads to use in developing required risk reduction programs
  • Revision of rules for building train consists
  • Prohibiting use of hand brakes on empty rails cars for controlling train movement in grade territory
  • Incorporation of the lessons learned from this derailment about fire-exposed jacketed pressure tank cars in first responder training programs

Rail Accident Report 20/04 is available online at https://go.usa.gov/xA3Bb and the docket for the investigation is available at https://go.usa.gov/xA3ZE.

As the National Transportation Safety Board continues to investigate an accident in Wyoming that killed two SMART TD members out of Local 446, it issued a pair of safety recommendations to Class I railroads and a recommendation to the American Short Line and Regional Railroad Association regarding train emergency brake communication.
Benjamin George “Benji” Brozovich, 39, and Jason V. Martinez, 40, both members of the Cheyenne, Wyo., local, died in the Oct. 4, 2018, accident. The NTSB recommendations follow.
To the Class I Railroads:
Review and issue guidance as necessary for the inspection of end-of-railcar air hose configurations to ensure the air hose configuration matches the intended design. (R-19-41)
Review and revise your air brake and train handling instructions for grade operations and two-way end-of-train device instructions to include: monitoring locomotive air flow meters, checking the status of communication between the head-of-train and end-of train devices before cresting a grade, and the actions to take if the air pressure at the rear of the train does not respond to an air brake application. (R-19-42)
To the American Short Line and Regional Railroad Association:
Alert your member carriers to (1) inspect the end-of-railcar air hose configurations to ensure the hose configurations match the intended design and (2) review and revise their air brake and train handling instructions for grade operations and two-way end-of-train device instructions to include: monitoring locomotive air flow meters, checking the status of communication between the head-of-train and end-of-train devices before cresting a grade, and the actions to take if the air pressure from the rear of the train does not respond to an air brake application. (R-19-43)
The NTSB investigation into the accident is ongoing. It issued a preliminary report on the accident last November.
Read the safety recommendations on the NTSB website.

The National Transportation Safety Board (NTSB) on Oct. 30 ruled that flaws in Union Pacific’s approach to inspecting, maintaining and repairing defects on the Estherville Subdivision helped to cause a March 2017 derailment that resulted in multiple tank cars spilling undenatured ethanol in Graettinger, Iowa.
A rail near a transition onto a bridge broke, causing 20 tank cars to derail in the accident that happened at 12:50 a.m. local time March 10, 2017. Fourteen of the tank cars spilled 322,000 gallons of ethanol, causing a fire that burned for more than 36 hours. Three nearby homes were evacuated as a result of the accident, which caused an estimated $4 million in damage, including the destruction of 400 feet of track and a 152-foot railroad bridge.

NTSB investigators survey the March 2017 derailment of a Union Pacific train carrying undenatured ethanol in Graettinger, Iowa.

During the NTSB hearing, board member Jennifer Homendy said she made a review of a decade’s worth of accident data for UP and the numbers showed one thing in common.
“Every year, track defects are the chief cause of accidents with UP,” she said.
Along Estherville’s 79-mile stretch, Homendy said that 102 defects of “marginal” and “poor” crossties were identified over a two-year period from 2015-17.
After the carrier received the reports of rail or crosstie defects, chief accident inspector Michael Hiller said UP didn’t take enough steps to fix the problems prior to the accident.
“The inspectors were going out and they were doing their inspections, and they were reporting the conditions of the tie,” Hiller said. “In many cases – more than 100, as member Homendy pointed out – there were remediation efforts, and it’s clear based on our observations post-accident that the remediation efforts restored the track back to its minimum condition that it needed to sustain traffic.
“We’re looking to see that things are not just restored back to the minimum…we know that doesn’t work. If you’re finding 10 or 12 crossties in a 39-foot section of track that are defective, it’s not a good practice to go in and replace two or three just to restore the track.”
Also contributing to the accident was what NTSB described as “inadequate oversight” on the part of the Federal Railroad Administration (FRA).
While FRA inspectors raised the carrier’s attention to track defects — the agency had just initiated a compliance agreement in late 2016 as a result of a fiery oil train derailment in Mosier, Ore. — and some action was taken, Hiller said not all enforcement measures, such as civil penalties, were used.
NTSB investigators also noted that FRA inspectors neglected to report some defective crosstie conditions.
After the Graettinger accident, Hiller said that the carrier has shown “very good response” to reports of tie defects and maintenance and has performed twice-weekly inspections on the subdivision in a post-accident agreement with FRA.
However, the NTSB did note that there was one week where the carrier inspected the subdivision only once.
“The extent of post-accident actions, while welcome, hints at the inadequacy of UP’s pre-accident maintenance and inspection program,” NTSB Chairman Robert Sumwalt said. “The railroad is supposed to look for and fix unsafe conditions as a matter of course.”
Finally, the use of U.S. DOT 111 tanker cars to transport the ethanol also worsened the environmental impact of the accident, investigators said.
Hiller said that 10 of the 14 tankers that breached met old DOT 111 specifications “identified as having a high probability of releasing hazardous materials.”
DOT 117 specifications established by the Pipeline and Hazardous Material Safety Agency (PHMSA) add reinforcement and other design features to cars transporting both crude oil and ethanol.
“The tougher design would have prevented the release,” Sumwalt said.
FRA identifies ethanol as the most hazardous material that is transported by rail in the United States. The denaturing process adds toxic compounds to make it unfit for human consumption and also lessens the tax burden for the carriers transporting it because it is not a beverage.
In the Graettinger accident, the ethanol was undenatured, meaning that the toxins were not added to the alcohol being transported.
“This seems to have had a beneficial effect on safety,” Sumwalt said. “Investigators found milder damage in this accident than in previous accidents with the same type of tank cars, but those involved denatured alcohol.”
It was suggested that a safety benefit might be achieved by getting rid of denaturants when transporting ethanol.
“Never before have I seen a regulation to make a hazardous material more hazardous,” Robert Hall, an expert in hazardous materials transport, said of the denaturing process. “It doesn’t make sense.”
A May 1, 2023, regulatory deadline has been set for all DOT 111 tank cars that carry ethanol to be changed over or retrofitted to meet the higher DOT 117 standards. In order to achieve that deadline, about 350 tank cars per month must be changed over.

Recommendations

At the hearing, NTSB issued three new safety recommendations and reiterated one safety recommendation to the FRA, PHMSA and UP. They address training on safety standards and available enforcement options for federal track inspectors, the need for research to determine if safety would be improved by transporting ethanol in an undenatured state, and the need for Union Pacific to re-examine track maintenance and inspection program standards on all routes carrying high hazardous flammable materials.
“The recommendations just issued, if acted upon, will result in better training for FRA track inspectors and clear guidance involving available enforcement options,” Sumwalt said. “They will result in UP re-examining its track maintenance and inspection program standards. Today’s recommendations will result in research by PHMSA into whether alcohol — ethanol — should be transported in an undenatured state and furthermore, a recommendation first issued in 2015 and reiterated today will result in progress milestone schedules for the phasing out of the DOT 111 tank cars for ethanol service by 2023, if acted upon.
“Otherwise, we risk a so-called sudden realization that isn’t sudden at all. We could have seen this train coming down the track.”
NTSB’s report states alcohol or drug use, and cell phone use were not factors in the accident, nor was the mechanical condition of the train, the performance of the train crew or the emergency response a factor. The full report will be available on the NTSB website when finalized.

The National Transportation Safety Board (NTSB) issued three urgent safety recommendations to the Federal Railroad Administration (FRA), acting upon the agency’s findings in two ongoing railroad accident investigations.

The Federal Railroad Administration (FRA) received one urgent safety recommendation based on NTSB findings in the agency’s investigation of the Feb. 4, 2018, collision of an Amtrak train and a CSX train near Cayce, S.C. The conductor and engineer of the Amtrak train died as a result of the collision. The NTSB issued two urgent safety recommendations to the Metropolitan Transportation Authority (MTA) based on findings from its investigation of the June 10, 2017, Long Island Rail Road (LIRR) accident in which a roadway worker died near Queens Village, N.Y.

In the investigation of the train collision in Cayce, South Carolina, investigators found that on the day before the accident, CSX personnel suspended the traffic control signal system to install updated traffic control system components for the implementation of positive train control (PTC). The lack of signals required dispatchers to use track warrants to move trains through the work territory.

In this accident, and in a similar March 14, 2016, accident in Granger, Wyo., safe movement of the trains, through the signal suspension, depended upon proper switch alignment. That switch alignment relied on error-free manual work, which was not safeguarded by either technology or supervision, creating a single point of failure.

The NTSB concludes additional measures are needed to ensure safe operations during signal suspension and so issued an urgent safety recommendation to the FRA seeking an emergency order directing restricted speed for trains or locomotives passing through signal suspensions when a switch has been reported relined for a main track.

“The installation of the life-saving positive train control technology on the CSX tracks is not the cause of the Cayce, S.C. train collision,” said NTSB Chairman Robert Sumwalt.

“While the collision remains under investigation, we know that signal suspensions are an unusual operating condition, used for signal maintenance, repair and installation, that have the potential to increase the risk of train collisions. That risk was not mitigated in the Cayce collision. Our recommendation, if implemented, works to mitigate that increased risk.” said Sumwalt.

During the investigation of the LIRR accident, the NTSB identified an improper practice by LIRR roadway workers who were working on or near the tracks. LIRR employees were using “train approach warning” as their method of on-track safety, but they did not clear the track, as required, when trains approached and their “predetermined place of safety” did not comply with LIRR rules and procedures.

The NTSB is concerned LIRR management is overlooking and therefore normalizing noncompliance with safety rules and regulations for proper clearing of tracks while using “train approach warning” for worker protection. The two urgent safety recommendations to the MTA call for MTA to audit LIRR’s use of “train approach warning” for worker protection, and, to implement corrective action for deficiencies found through the audit.

The full safety recommendation reports for these urgent safety recommendations are available online at https://goo.gl/z87Dpz and https://goo.gl/LVVef3.

WASHINGTON (Jan. 11, 2018) — The National Transportation Safety Board (NTSB) issued four railroad related safety recommendations in concert with the agency’s publication of two railroad accident briefs Thursday, Jan. 11.

The recommendations and briefs stem from the NTSB’s investigations of a railroad employee fatality in Kansas City, Kansas, and a derailment near Heimdal, N.D. The accidents are unrelated.

Recommendation to Union Pacific concerning employee fatality

A Union Pacific Railroad (UP) foreman died after being struck by a remote-control train during switching operations at the east end of Armourdale Yard, Kansas City, Sept. 29, 2015. The NTSB determined the probable cause of the accident was the foreman being in the gage of the track, for unknown reasons, while a train switching movement was being performed by another crew. The report also states inadequate radio communications and inadequate work coordination between crews working in the yard contributed to the accident.

In the course of the investigation the NTSB learned Union Pacific employees received frequent, non-critical, man-down alarms which the NTSB believes likely reduced the attention and reaction crewmembers made to actual critical alarms.

A man-down alarm is an audible warning transmitted of the yard’s radio channels from a remote-control unit (used to remotely control locomotives in the yard) indicating the remote-control unit is not in a vertical position and its operator may be in danger. As a result of the investigation the NTSB issued a safety recommendation to the Union Pacific Railroad to develop and implement a modification to the man-down alarms that would allow workers to differentiate between legitimate and non-critical alarms.

Recommendation to BNSF concerning derailment

A broken wheel led to the derailment of six of the 107 loaded tank cars carrying crude oil in a Burlington Northern Santa Fe crude (BNSF) oil unit train May 6, 2015, near Heimdal, N.D. No injuries or fatalities were reported in connection with the derailment, however five of the derailed tank cars breached, releasing about 96,400 gallons of crude oil. A fire ensued, forcing the evacuation of about 30 people from Heimdal and the surrounding area due to the smoke plume.

The NTSB determined the left wheel, in the second position on car 81 was broken due to a vertical split rim which led to catastrophic failure of the wheel due to multiple overstress fractures.

As a result of the investigation the NTSB issued two safety recommendations to the Federal Railroad Administration (FRA) to research and evaluate wheel impact load thresholds and to mandate remedial actions for railroads to avoid or identify mechanical defects identified by wheel impact load detectors.

A third recommendation was issued to both the FRA and the Association of American Railroads (AAR) seeking collaboration in evaluation of safe peak vertical load thresholds to determine remedial actions for suspected defective wheel conditions in high-hazard flammable train service.

The Heimdal, North Dakota, railroad accident brief is available online at http://go.usa.gov/xndbK and the Kansas City, Kansas, railroad accident brief is available at https://go.usa.gov/xndbN.