NTSB Paulsboro Presentation
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Transcript of NTSB Paulsboro Presentation
![Page 1: NTSB Paulsboro Presentation](https://reader034.fdocuments.net/reader034/viewer/2022052302/58a5a3881a28ab1a628b478b/html5/thumbnails/1.jpg)
Conrail Freight Train Derailment
with Vinyl Chloride Release
1
Paulsboro, New Jersey
November 30, 2012
Paul L. Stancil, Investigator-in-Charge
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2
N
Tank Car 10:
DOT-105
Vinyl Chloride
Punctured
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3
Injuries and Damages
• Emergency responders and residents
exposed to vinyl chloride
• 28 residents treated at hospitals
• $451,000 equipment damage
• $30 million emergency response
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4
56 ft
Swing span
N
Mantua Creek
Paulsboro
Moveable Bridge
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5
Mantua Creek
Paulsboro
Moveable Bridge
Open
56 ft
March 2 - December 1
N
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6
Mantua Creek
Paulsboro
Moveable Bridge
March 2 – December 1
N
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7
Slide Lock Operation
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8
Slide Lock Operation
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Bridge Operation Problems
9
Nu
mb
er
of
Tro
ub
le T
ick
ets
Hurricane Sandy
Derailment
Oct. 29, 2012
Nov. 30, 2012
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10
Mantua Creek
November 29, 2012 - about 3:00 a.m.
Gap
N
East end
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11
N
Mantua Creek
November 29, 2012 - about 11:00 p.m.
Slide locks
partially engaged
Slide locks
unlocked
West end
East end
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12
N
Mantua Creek
November 30, 2012 - 6:52 a.m.
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13
Mantua Creek
November 30, 2012 - 7:02 a.m.
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14
37 inches
Punctured Tank Car
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Emergency Response
• Initial notification
• First responders staged in “hot zone”
• No respiratory protection used
• Unified command established
after 6 hours
15
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Investigative Hearing July 9-10, 2013
• Conrail bridge operations
• Initial emergency response
• Hazardous materials incident
management
• State and federal emergency
response actions
16
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Safety Issues
• Qualification of bridge inspectors
• Conrail safety management
• Hazardous materials communications
• Hazardous materials response protocols
• Firefighter training and qualifications
• Emergency planning and preparedness
• Rail corridor risk management
17
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Proposed Safety Recommendations
• U.S. Department of Transportation
• Federal Railroad Administration
• Consolidated Rail Corporation
• Association of American Railroads
• American Short Line and Regional Railroad
Association
• International Association of Fire Chiefs
• National Volunteer Fire Council
• New Jersey State Agencies
18
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Reiterated Recommendations
• Federal Railroad Administration
• Pipeline and Hazardous Materials
Safety Administration
19
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Investigation Team
• Paul Stancil Investigator-in-Charge
• James Southworth On-scene IIC
• Tim DePaepe Signals
• Rick Downs Emergency Response
• Muhamed El-Zoghbi Hazardous Materials and Emergency Response
• Joe Epperson Materials Laboratory
• Gena Evans Editor
• Cy Gura Track and Structures
20
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Investigation Team - continued
• Joe Gregor Electrical Engineering
• Steve Jenner Human Performance
• Cassandra Johnson Recorders
• Donald Kramer Materials Laboratory
• Matt Nicholson Investigative Hearing Officer
• Mike Richards Meteorology
• Ted Turpin Operations
• Dave Watson Mechanical
21
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Staff
22
• Bob Beaton
• Shannon Bennett
• Steve Blackistone
• Larry Bowling
• Alex Burkett
• Jennifer Cheek
• Stephanie Davis
• Antion Downs
• Ann Gawalt
• Georgetta Gregory
• Erik Grosof
• Richard Hipskind
• Mike Hiller
• Gary Helmer
• Mark Jones
• Nancy Mason
• Kelly Nantel
• Alice Park
• Ruben Payan
• Carl Schultheisz
• Joe Scott
• Eric Stolzenberg
• Christy Spangler
• Jane Terry
• John Vorderbrueggen
• Terry Williams
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Parties to the Investigation
• Consolidated Rail Corporation (Conrail)
• Federal Railroad Administration
• Brotherhood of Locomotive Engineers and Trainmen
• International Association of Sheet Metal, Air, Rail, and Transportation Workers
• TrinityRail
• State of New Jersey
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Conrail Operating Issues
24
Ted Turpin
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Safety Issue
Training and qualification of train crews
for moveable bridge inspection
25
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Conductor’s Training
• Inspected with an experienced conductor
four years earlier
• No formal training
• Had not inspected a bridge until accident
• Uncertain when slide locks were fully
engaged
• Answers did not demonstrate knowledge
26
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Physical Evidence on Bridge
27
No damage to components in circled areas
East end slide locks - locked
Direction of travel open
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Physical Evidence on Train
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Bridge Not Locked
• Inadequate training
• Uncertain answers
• No damage to slide locks
• Strike marks on wheels
• Erroneously determined locked
29
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Conrail Training
• No specific instructions for inspecting
moveable bridges
• No posters or other job aids
• Other crewmembers had no formal
training
• Manager confirmed no formal
instructions
30
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Conrail Training
• No written instructions in training
program
• Training comes from on-the-job
• Inspecting bridge random
31
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Conrail Training
• Conrail did not ensure inspections by
qualified employees
• Unstructured on-the-job training
• Did not prepare crews
32
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Conrail Postaccident Actions
• No permission to pass stop signals
• Crews notify dispatcher
• Dispatcher informs trouble desk
• Notify maintenance department
• No longer rely on operating crews
33
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FRA Safety Advisory
• Evaluate the design of moveable
bridges
• Evaluate operating rules for stop
signals
• Review the adequacy of all training
• Encouraged railroads to take
corrective action
34
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FRA Safety Advisory
• Operating employees could be
qualified
• Qualified employee was not defined
• No specific training was described
• FRA does not track implementation
• FRA does not enforce
35
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Existing Regulation for Passing over a
Broken Rail (49 CFR 213.7(d))
• Minimum experience
• Requires training with examinations
• Periodic requalification
• Establishes specific subjects
• Requires watching and be prepared to stop the train
• Enforceable by FRA
36
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37 37 37
Muhamed El-Zoghbi
Hazardous Materials Emergency
Response
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Issue Areas
• Hazardous Materials Communications
• Emergency Response Protocols
• Community Protective Action Measures
• Community Awareness Programs and
Emergency Response Planning
• Oversight of Emergency Operations Plans
• Hazardous Materials Routing and Risk Analysis
38
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Hazardous Materials Communications
• Responders need train consists to identify,
locate, and secure hazardous materials
• Train consist not immediately available to
responders at all times
• Conrail retained possession for 3.5 hours
39
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40
Position
in Train Tank
Car
Number Maximum
Quantity
Emergency
Contact
Number
Identity
of
Chemical
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Hazardous Materials Communications
• Instructions to crews may be contributing
to delays in emergency information
• Railroad emergency response information
inconsistent with and not as protective as
Emergency Response Guidebook
41
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Hazardous Waste Operations and
Emergency Response (HAZWOPER)
• Emergency responders knew uncontrolled hazardous materials release occurred
• OSHA HAZWOPER standard, 29 CFR 1910.120, requires:
- Site assessment
- Appropriate emergency operations
- Personal protective equipment
42
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43
Initial Command
Post
Potential Recommended
Initial Evacuation Areas
(Weather-dependent)
½ mile
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44
½ mile
50 yards
Breached
Tank Car
Initial Command Post location
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Hazardous Waste Operations and
Emergency Response (HAZWOPER)
• Responders exposed to vinyl chloride
• Other local and state agencies failed to
comply with HAZWOPER standard
• Citations for violations were issued
45
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Community Protective Action Measures
• Initial evacuation and shelter-in-place decisions based on erroneous reports
- Liquefied petroleum gas vs. vinyl chloride
- Vapor cloud reported “nontoxic”
• Inadequate measures to correct errors and misinformation
46
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• Fact-based decisions regarding
community exposure did not occur
• Estimate endangered area and
potential harm to community
• Determine concentrations of released
hazardous material within area
47
Community Protective Action Measures
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Example ALOHA Model
Red, orange, and yellow zones indicate where specific level of concern thresholds exceeded
48 Source: NOAA.gov
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Community Awareness Programs and
Emergency Response Planning
• Responders and community unfamiliar with
hazardous materials routinely transported
through Paulsboro
• Railroad community awareness is voluntary
• Communities unprepared for hazardous
materials transiting their neighborhoods
49
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50
180,000 lbs
100 lbs
Community Awareness Programs and
Emergency Response Planning
• Chlorine
- Fixed facility: 100 lbs (a cylinder) - Planning
required
- Rail: tank car (180,000 lbs) – No planning
required
• Fixed facility threshold planning quantities often
lower than quantities transported by rail
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• Emergency Operations Plans:
- Assign responsibility and set lines of authority
- Describe how people will be protected
- Identify resources for response
• In New Jersey - EOP recertification every 4 years
• Paulsboro EOP was 2 years past due
recertification
51
Oversight of Emergency Operations Plans (EOP)
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• State relies on counties to conduct reviews
• No audits or procedures to verify
capabilities
• Many municipalities are non-compliant
• Inadequate accountability for non-compliance
52
Oversight of Emergency Operations Plans (EOP)
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Routing and Risk Analysis
• Rail Corridor Risk Management System (RCRMS) software is inadequate for shortline railroads
• RCRMS does not assess risk when alternate routes are unavailable
• Conrail aware of shortcomings and failed to conduct thorough risk assessment
53
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