Examining the state of rail safety in the aftermath of the derailment in East Palestine, Ohio before the Railroads, Pipelines, and Hazardous Materials Subcommittee Committee on[...]

​​​​​​​Good afternoon, Chairman Nehls, Ranking Member Wilson, and members of the subcommittee. Thank you for inviting the National Transportation Safety Board (NTSB) to testify before you today regarding rail safety following our investigation into the Norfolk Southern Railway (NS) derailment and hazardous materials release in East Palestine, Ohio.[1]

As you know, the NTSB is an independent federal agency charged by Congress with investigating every civil aviation accident in the United States and significant events in other modes of transportation-railroad, transit, highway, marine, pipeline, and commercial space. We determine the probable causes of the accidents and events we investigate and issue safety recommendations aimed at preventing future occurrences. In addition, we conduct transportation safety research studies and offer information and other assistance to family members and survivors for each accident or event we investigate. We also serve as the appellate authority for enforcement actions involving aviation and mariner certificates issued by the Federal Aviation Administration (FAA) and the US Coast Guard, and we adjudicate appeals of civil penalty actions taken by the FAA.

The NTSB does not have authority to promulgate operating standards, nor do we certificate organizations, individuals, or equipment. Instead, we advance safety through our investigations and recommendations, which are issued to any entity that can improve safety. Our goal is to identify issues and advocate for safety improvements that, if implemented, would prevent injuries and save lives.

Since 1967, the NTSB has been at the forefront of railroad safety. We have a long record of highlighting numerous safety issues on our railways, including the need for an aggressive phase-out of DOT-111 tank cars in hazardous materials service.

I believe it is important, as we have this discussion today, to keep in mind that rail passenger and freight transportation in the United States is far safer than road transportation. The United States confronts an ongoing public health crisis on our roadways in every corner of this country, losing over 40,000 lives annually in crashes on our roadways.[2] I would never want to see traffic shift away from railways to roadways-particularly hazardous materials traffic. What we should strive for is to shift passenger and freight transportation from our deadly roadways to far safer modes of transportation, like rail. However, as I testified before this committee in January and now reiterate, we must also be clear that the only acceptable number of accidents​ and injuries-fatal and nonfatal-is zero, and although rail transportation is ​​comparatively safe in contrast to highway transportation, we must still work to ensure that no lives are lost in rail transportation and no communities are impacted by hazardous materials releases. There is much work left to be done.

In total, the NTSB currently has over 215 open rail safety recommendations.[3] These include 5 recommendations to the US Department of Transportation (DOT), 98 recommendations to the Federal Railroad Administration (FRA), and 15 recommendations to the Pipeline and Hazardous Materials Safety Administration (PHMSA). There are also 116 recommendations to the FRA that are closed with unacceptable action.[4] In addition, NS has 17 open recommendations and 3 recommendations classified Closed-Unacceptable Action. Finally, eight recommendations are currently open to all the Class I railroads. The collisions and derailments we see in our investigations are tragic because they are preventable, and we believe the safety issues we identify in these investigations should be acted on swiftly.

As examples, I'd like to highlight just three investigations we launched following the completion of our East Palestine investigation.

This past Friday, July 19, 2024, at about 12:38 p.m., a NS conductor sustained severe injuries during switching operations at Lambert's Point Yard in Norfolk, Virginia. This follows our investigation of a March 7, 2023, incident where a NS conductor was killed when the train he was riding collided with a dump truck as they entered a private grade crossing in the Cleveland-Cliffs Incorporated steel plant in Cleveland, Ohio.[5] The conductor was riding on the end platform of the lead railcar during a shoving movement when he was pinned between the railcar and the dump truck during the collision, a procedure that is authorized by railroad operating rules.

This also follows the July 6, 2024, incident where a Union Pacific employee was killed in a rail yard in Melrose Park, Illinois, when he was riding on a tank car during a shoving movement and was pinched between it and another passing train.[6] The NTSB has issued multiple recommendations aimed at ensuring employees are not riding train cars through certain shoving movements, and we intend to continue investigating and advocating on this issue.[7] I want to emphasize that over half-12 out of 23-of our open investigations in rail involve employee fatalities. Accidents on yard track, in particular, are increasing, and I urge this committee to exercise robust ​oversight for employee safety.

In the early morning of July 5, 2024, a Canadian Pacific Kansas City Railroad train derailed 29 cars near the town of Bordulac, North Dakota. The 8,850-foot train consisted of one headend locomotive, one rear distributed power locomotive, 126 loaded cars, and 25 empty cars. Preliminary information indicates that the derailed cars included 6 methanol, 11 anhydrous ammonia, and 12 propylene pellet cars. There was a postaccident fire involving methanol and propylene pellets, and at least four anhydrous ammonia cars were leaking, three of which are believed to be breached. There are no initial reports of injuries, but there was a voluntary evacuation of two houses. Due to ongoing work to mitigate the hazmat on scene, our investigators have not been able to visually inspect the tank cars, and some of the tank cars have not yet been identified due to their condition. One of the tank cars transporting methanol, a flammable liquid, was reportedly a DOT-111 tank car. Investigators will confirm car types when they are able to perform detailed damage assessments of all the tank cars involved in the accident. Underlining our recommendations coming out of the East Palestine investigation, though, I wanted to note the presence of a possible DOT-111 tank car in this accident. As part of this investigation, we will assess the performance of all the tank cars involved.

All information on these three investigations is still preliminary, but more will be forthcoming, and I am happy to discuss as much as I can at this point.

East Palestine Findings and Recommendations

Turning to East Palestine, on February 3, 2023, about 8:54 p.m., eastbound NS train 32N derailed 38 mixed freight railcars at milepost 49.5 on the NS Fort Wayne Line of the Keystone Division in East Palestine, Ohio. Three tank cars carrying flammable and combustible hazardous materials were mechanically breached during the derailment. A fire ignited during the derailment and grew to involve lading released from these three mechanically breached tank cars, additional derailed tank cars carrying both hazardous and nonhazardous materials, and freight cars. Emergency responders established a 1-mile evacuation zone that affected about 2,000 residents. The derailed equipment included five hazardous materials tank cars carrying vinyl chloride monomer (VCM), a compressed liquified flammable gas offered for shipment as "UN1086 vinyl chloride, stabilized, 2.1." The five VCM tank cars were not mechanically breached during the derailment, but over the next day, four of those tank cars were exposed to fires and released material from pressure relief devices. These releases ceased on the afternoon of February 4. Acting on information provided by NS and its contractors that a dangerous chemical reaction was occurring within a VCM tank car, the incident commander managing the response chose to expand the evacuation zone and perform a vent and burn (a deliberate breach of a tank car) on all five derailed VCM tank cars. The incident ​​commander was not aware of dissenting opinions the VCM shipper had provided to NS and its contractors. A contractor hired by NS breached the VCM tank cars at 4:37 p.m. on February 6, releasing and igniting their lading. No injuries were reported during the derailment or emergency response.

What We Found

The NTSB determined the derailment occurred because a bearing on a hopper car overheated and caused an axle to separate. There was not enough evidence to determine if a mechanical inspection conducted before the derailment failed to identify signs of bearing failure; the bearing may not have been showing visible problems at the time of the inspection.

A hot bearing detector traversed by train 32N detected an elevated temperature on the overheating bearing, but the low priority alert it transmitted to railroad personnel did not reflect the true condition of the failing bearing. Because of design constraints, hot bearing detectors are likely to indicate misleadingly low bearing temperatures. This limit on detector performance, combined with NS's standard operating procedures and the spacing between detectors, meant that the train's crew did not have adequate warning to stop the train before the derailment.

Researc​h will be necessary to determine if changes to wayside bearing defect detection systems-such as lower alert and alarm thresholds-would produce a significant safety improvement. Research is also necessary to determine what operational responses to bearing alerts and alarms are sufficient to prevent derailments.

Our investigation also found that the state of Ohio's laws regarding volunteer firefighter training were insufficient to support a safe emergency response to the derailment. Further, the emergency response lacked efficient coordination because the responding agencies did not have common radio channels. Also hampering efforts was the illegibility of the railcar placards after they were exposed to fire. Delays in NS transmitting train consist information to emergency responders also increased responders' and the public's exposure to postderailment hazards.

The postderailment fires likely began because of hazardous materials released from a punctured DOT-111 tank car. The subsequent release of VCM from mechanically intact DOT-105 tank cars likely would not have occurred if the DOT-111 tank cars in the consist had survived the derailment. Since 1991, the NTSB has raised concerns about DOT-111 tank cars. We have repeatedly stated that the presence of DOT-111 tank cars carrying hazardous materials in a train can increase the risk of more resilient tank cars releasing hazardous materials following a derailment; the Association of American Railroads' (AAR's) definition of key train does not account for this. Although voluntary phase out of the remaining DOT-111 tank cars in hazardous materials service is technically possible, it is unlikely because of economic and ​business disincentives.

The VCM in the derailed DOT-105 tank cars in East Palestine remained in a stabilized environment (that is, was unable to undergo polymerization, a potentially dangerous chemical reaction) until those tank cars were deliberately breached with explosives (the vent and burn procedure). On-scene temperature trends did not indicate that a polymerization reaction was occurring, and postaccident examinations confirmed this. The vent and burn procedure was not necessary to prevent a polymerization-induced explosion. One source of information about polymerization consulted by NS and its contractors, The Chlorine Institute's Pamphlet 171, included misleading information about signs of polymerization. NS and its contractors continued to describe polymerization as an imminent threat when expert opinions and available evidence should have led them to reconsider their course of action. NS compromised the integrity of the decision to vent and burn the tank cars by not communicating expertise and dissenting opinions to the incident commander making the final decision. This failure to communicate completely and accurately with the incident commander was unjustified. The significant local and environmental impacts of a vent and burn decision demonstrate the need for federal guidance about when to conduct a vent and burn.

Lastly, inward- and outward-facing recorders can help railroads verify train crew actions and investigators improve the quality of investigations and identification of safety enhancements, and without a requirement, we have missed an opportunity to record important safety data.

Probable Cause

The NTSB determined that the probable cause of NS train 32N's derailment was the failure of the L1 bearing on the 23rd railcar in the consist that overheated and caused the axle to separate, derailing the train and leading to a postderailment fire that likely began with the release of a Class 3 flammable liquid from a DOT-111 tank car that was punctured during the derailment. Contributing to the postderailment fire and the severity of the hazardous materials release was the continued use of DOT-111 tank cars in hazardous materials service. Also contributing to the severity of the hazardous materials release were the failure of NS and its contractors to communicate relevant expertise and dissenting opinions to the incident commander, and the inaccurate representation by NS and its contractors that the tank cars were at risk of catastrophic failure from a polymerization reaction, which created unwarranted urgency and led to the unnecessary decision to vent and burn five derailed VCM tank cars to prevent a polymerization-induced tank car rupture. Contributing to the exposure of emergency responders and the public to postderailment hazards were NS's delay in transmitting the train consist information to emergency responders and Ohio's insufficient training requirements for volunteer firefighters.

​What We Recommended

As a result of this investigation, we issued 34 new recommendations and reiterated 1 previously issued recommendation. We also classified four previously issued recommendations.

We recommended the FRA to research bearing defect detec tion systems and use the results to establish regulations on the following related subjects:

• ​Railroads' use of bearing defect detection systems, including thresholds for alerts and alarms and distances between wayside detectors.
• Railroads' operational responses to bearing alerts and alarms.
• Installation, inspection, and maintenance of wayside bearing defect detection systems.
  

We issued a recommendation to Ohio to amend its statute limiting volunteer firefighter training and bring its training requirements in line with a widely accepted standard. To expand the reach of lessons learned at East Palestine, we recommended that the International Association of Fire Chiefs, the International Association of Fire Fighters, and the National Volunteer Fire Council inform their members of the derailment and fire and encourage them to adopt training that meets a widely accepted standard. We also recommended that the National Volunteer Fire Council identify barriers to volunteer firefighter training and actions to address them.

To improve local preparedness, we recommended that the Columbiana County Emergency Management Agency develop a policy to immediately provide train consists to emergency responders and update its emergency plans to incorporate lessons learned from the East Palestine derailment.

Our investigation report classified Safety Recommendation R-07-4 to PHMSA Closed-Acceptable Action. This recommendation, previously classified Open-Unacceptable Response, asked PHMSA to require railroads to immediately provide emergency responders with train consist information. We are grateful to PHMSA for taking this action. We also recommended that NS review and revise its practices to ensure a train's consist is immediately communicated to first responders. We made a new recommendation that PHMSA require that placards used to identify hazardous materials be able to survive accidents and fires.

We issued additional new recommendations to PHMSA expanding and accelerating the current phase out of DOT-111 tank cars from hazardous materials service and expanding the definition of high-hazard flammable trains (HHFTs) to ​​include a wider variety of hazardous materials and account for variations in how well different tank car specifications survive derailments. We made a related recommendation to the AAR to account for the risk posed by certain tank cars in its definition of key train. We also recommended that the AAR take steps to require manufacturers of tank car service equipment to demonstrate that their products are compatible with a tank car's intended lading, and that the FRA monitor the AAR's progress to ensure it addresses weaknesses in its approval process.

Regarding the vent and burn decision, we recommended that:

• ​NS establish a policy of communicating all expert opinions to the full incident command, share information collected by its emergency response contractors with entities that provide hazardous materials guidance, and update its submissions to the PHMSA incident database.
• The FRA disseminate current and updated versions of its existing study on the vent and burn method to help guide incident commands in the future.
• PHMSA spread awareness of the FRA's most current guidance by referencing it in the next edition of the Emergency Response Guidebook.
• The Chlorine Institute review and revise its pamphlet on VCM to ensure that it is accurate and suited to supporting emergency responses, and that it change its Chlorine Emergency Plan program to make sure specialized emergency response contractors can appropriately respond to chemical hazards during a VCM incident.
• Oxy Vinyls update its safety data sheet for VCM to ensure that it is accurate and develop a policy to ensure that its expertise is communicated to the full incident command.
• The American Chemistry Council and The Chlorine Institute make their members aware of the events at East Palestine and emphasize the importance of shippers communicating their expertise to the full incident command.
  

We made an additional recommendation to the International Association of Fire Chiefs, the International Association of Fire Fighters, and the National Volunteer Fire Council to encourage the distribution of federal guidance about the vent and burn method.

We also recommended that the secretary of transportation and the FRA require the installation and use of inward- and outward-facing audio and image recorders on locomotives, obtaining legislative authority to act if necessary. In addition, we reiterated a recommendation that we first made to all the Class I railroads in 2013 that they should install and use such recorders in advance of a requirement to do so.

​Each of these recommendations is detailed in our final report, and I am happy to discuss any of them in detail. I urge this committee to closely examine the recommendations in which we have identified that legislative authority may be necessary for implementation, particularly those related to the following.

• Accelerating Phase-out of DOT-111 Tank Cars for Flammable Liquids. The Fixing America's Surface Transportation (FAST) Act (Public Law 114-94) phased out legacy DOT-111 specification tank cars for transporting flammable liquids, such as crude oil and ethanol; however, certain other flammable liquids may still be transported in such tank cars until May 1, 2029, under the law. This includes the DOT-111 tank car transporting flammable liquid that likely started the fire in East Palestine.
• Prohibiting Other Hazardous Materials in DOT-111 Tank Cars. We recommend prohibiting other hazardous materials in DOT-111 tank cars, including combustible liquids. Any nonpressure tank car transporting hazardous materials must meet or exceed the safety standards of DOT-117 specification tank cars. We emphasize meeting or exceeding the DOT-117 specification because we do not want to see such hazardous materials moved from DOT-111 tank cars to AAR-211 tank cars, which also pose a risk in derailments.
• Revising and Expanding the Definition of High-Hazard Flammable Train. The FAST Act codified the definition of an HHFT. The train in the East Palestine derailment was not an HHFT because it did not contain a block of 20 or more than 35 total loaded tank cars of a Class 3 flammable liquid, as defined in the act. We believe the definition of an HHFT should include a broad range of hazardous materials, including flammable gases and combustible liquids. We recommended that PHMSA seek legislative authority if necessary to revise the definition of HHFT to account for differences in survivability between tank car specifications and to include hazardous materials other than flammable liquids that can contribute to cascading hazardous materials releases. We have previously stated in comments to the HHFT rulemaking that the threshold of 20 or more than 35 total loaded tank cars of a Class 3 flammable liquid is far too high.
• Requiring Recorders on Freight Rail. The FAST Act required railroads providing regularly scheduled intercity rail passenger or commuter rail passenger transportation to the public to install inward- and outward-facing image recording devices in all controlling locomotive cabs and cab car operating compartments in passenger trains. However, the law did not require freight railroads to install such devices, and when the FRA issued its final rule implementing the FAST Act requirements, it left out freight railroads, citing this reason. We have recommended recorders for freight railroads since 2010, and​ ​in the East Palestine report, we issued new recommendations calling on both the secretary and the FRA to issue regulations to require them, and for the FRA to require that railroads routinely review recordings to ensure safety. We recommended that they seek legislative authority, if necessary.
  
• Providing increased funding for the fire service. PHMSA provides grant funding to states and other entities (through competitive grants) for training emergency responders. Our investigation found that volunteer firefighter training was not sufficient to support a safe emergency response to the East Palestine derailment and that the emergency response lacked efficient coordination because the responding agencies did not have common radio channels.​
  
  ​​​ Radio systems for emergency responders are subject to numerous regulations and standards governing their use and minimum interoperability requirements, including Federal Communications Commission (FCC) regulations. Authorities with jurisdiction are ultimately responsible for ensuring interoperability through suitable equipment, protocols, and training; however, they may not have the means to do so, as radio interoperability can cost millions of dollars.
  
  While we recognize the committee does not have jurisdiction over the FCC, it could increase funding for states and other entities, as well as additional eligibility for radio interoperability, within the Hazardous Materials Emergency Preparedness Fund.​
• 
  Rescheduling of Marijuana&
  
  
  As we discuss rail safety, I also want to call your attention to the comments that we have submitted in response to the US Drug Enforcement Administration's (DEA's) notice of proposed rulemaking, "Schedules of Controlled Substances: Rescheduling of Marijuana."[8] The proposed rule would transfer marijuana from Schedule I to Schedule III of the Controlled Substances Act. As you know, the NTSB has long been concerned about impairment in all modes of transportation. This includes our concerns about marijuana use among crewmembers and other safety-sensitive personnel in rail. We believe there will be a serious negative impact on transportation safety if the DEA moves forward with rescheduling without addressing the issues further detailed in our comments, which are appended to my testimony.
  
  
  ​Conclusion
  
  
  Again, thank you for the opportunity to discuss these critical rail safety issues and the NTSB's perspectives and recommendations with the committee today. We strongly believe that continued vigilance and improvement are needed in our rail system. We recognize the progress that has been made; yet there will always be room for more when it comes to safety. We stand ready to work with the committee to continue improving rail safety, which includes ensuring that the NTSB has the resources needed to carry out our essential mission.
  
  
  To that end, I thank you on behalf of our entire agency for your committee's strong bipartisan work to ensure a robust reauthorization for the NTSB in the recently passed FAA bill. I also thank you for your steadfast support for bolstering our agency funding in FY 2024. It was your support that ensured that funding increases for safety crossed the finish line. I urge your continued consideration for additional resources at the NTSB as Congress moves forward with FY 2025 appropriations.
  
  
  Thank you again, and I am happy to answer your questions.
  ​[1] National Transportation Safety Board. Norfolk Southern Railway Train Derailment with Subsequent Hazardous Material Release and Fires, East Palestine, Ohio, February 3, 2023. Washington, DC: NTSB 2024; Rpt. No. RIR 24/05.
  [2] US Department of Transportation, National Highway Traffic Safety Administration. Traffic Safety Facts: Early Estimate of Motor Vehicle Traffic Fatalities for the First Quarter of 2024. Washington, DC: NHTSA, 2024.
  
  ​[3] A report of all open safety recommendations related to rail (nontransit) can be accessed here:
  
  https://data.ntsb.gov/carol-main-public/query-builder/route/?t=published&n=28.
  [4] A report of all closed-unacceptable safety recommendations related to the FRA can be accessed here: https://data.ntsb.gov/carol-main-public/query-builder/route/?t=published&n=33.
  
  [5] NTSB. Norfolk Southern Conductor Fatality, Cleveland, Ohio, March 7, 2023.
  [6] A shoving movement is the process of pushing railcars or a train from the rear with a locomotive.
  [7] Safety Recommendations R-23-19 and -20​.
  
  ​[8] 89 Federal Register 44597