Closing Remarks: On the Investigation into the Norfolk Southern Railway Derailment and Hazardous Materials Release

​Our deliberations have now concluded.

I thank my fellow Board members and their staff for their preparation and participation in today’s meeting. We discussed important topics that will benefit the final report and inform our safety recommendations. 

As we’ve heard over the course of this investigation and this meeting, this derailment and hazardous materials release was devastating…for an entire community…for the train crew…for emergency responders…for the incident commander…and for countless others.

We can’t change the past. 

What we can do, based on facts, is work to ensure this never happens again.

That has been the NTSB’s ONLY goal since February 3, 2023. 

To that end, I want to thank the NTSB staff for their outstanding work on this investigation; for their fortitude in the face of mounting pressure; for their laser focus on the facts, the evidence; and for their objective analysis of those facts and evidence. 

The 17 staff members who worked on this investigation has a combined 473 years of rail and hazmat expertise. One of them has 39 years of fire and rescue experience. Another, 35 years of experience as a chemist; 31 years as a fire investigator. Another is a materials engineer. One is an internationally recognized technical expert in hazardous materials accident investigation. I could go on.

The point is, this investigative team, without exaggeration, are the best and the brightest in their field…and I KNOW every single one of them takes our mission to heart. 

That mission is not to place blame, not to assign motive; that’s for the courts and enforcement agencies to address. Our mission is solely to improve safety — to save lives. 

Our investigations are never conducted for the purpose of determining the rights or liabilities of a party. 

We collect the evidence, evaluate the facts, and develop lessons learned with one goal in mind: to prevent the next train derailment and hazardous materials release.

Which is why I’m so deeply troubled with how Norfolk Southern approached this investigation. 

When we conduct an investigation, we work under what we call “the party system,” meaning we bring together technical experts from those involved in a train derailment to help us gather and develop the facts around the investigation. 

They are not part of the analysis or development of the findings, probable causes, or safety recommendations, but they are critical to helping us obtain information that we need to carry out our safety mission. 

At the same time, parties get access to what we are finding in real-time over the course of our investigation, so they don’t have to wait until the conclusion to make safety change. 

Norfolk Southern was one of the parties to this investigation. There are regulations governing the conduct of parties, and rules the parties agree to in writing.

Numerous times, Norfolk Southern delayed or failed to provide critical investigative information to our team. 

Twice, at the request of staff, I called Norfolk Southern stating I would issue subpoenas to get the information if it wasn’t immediately provided to our team. 

For example, in interviews with our team, SPSI — Norfolk Southern’s contractor — maintained that they did not take or keep written records on trending tank car temperatures. 

However, in later interviews with their employees, we found that they did keep those records...there were text messages between Norfolk Southern and SPSI employees. 

It took about two months before our team received those communications — two months before those communications were provided to our team. 

As stated in the report we just adopted, our Investigator-In-Charge told Norfolk Southern on February 3rd to preserve all evidence for the investigation. 

Over the next two weeks, he requested five times the full download of locomotive event and image recorders. 

On February 16th, we were informed by Norfolk Southern that all but about 20 minutes was erased “because the locomotives were returned to service.” 

The day before the investigative hearing last June, Norfolk Southern retained, without our knowledge, the services of a private company to test commercially purchased vinyl chloride — not vinyl chloride from the five tank cars that derailed, but vinyl chloride that they purchased off the shelf. Then, instead of using their investigation for their own purposes, they submitted it for inclusion in the NTSB record.

Not only did these actions violate our party agreement, but they violated the regulations governing our evidence collection, which state:

NTSB has exclusive authority to decide timing, manner and method of testing and examination of evidence, and extraction of data. 

Further, under our regulations: 

Only the Board has the authority to decide on the way in which testing under this section will be conducted, including decisions on the person that will conduct the test, the type of test that will be conducted, and any individual who will witness the test. Those decisions are committed to the discretion of the Board. 

Party rules and our regulations are in place to preserve our agency’s independence and the integrity of our investigations. 

Norfolk Southern tried to submit their own investigation under the guise of a party submission, not once, not twice, not three times, but four times.

The investigator-in-charge reminded them numerous times that, under our regulations, parties “may submit to the NTSB written proposed findings to be drawn from the evidence produced during the course of the investigation.” 

Evidence produced during the course of the investigation.

In other words, parties are afforded the privilege — not the right — to develop proposed findings from the evidence of our investigation. Parties are not permitted to manufacture their own evidence and develop their own set of facts outside the NTSB investigative process, which is exactly what Norfolk Southern did.

Recall, the evidence was derived not from the accident scene, but from commercially purchased products. 

Our investigator-in-charge rejected the party submission containing Norfolk Southern’s extraneous testing not once, but twice. Norfolk Southern then went to our General Counsel and​ appealed, who promptly and appropriately informed them the investigator-in-charge has the final say. 

In fact, our regulations state the investigator-in-charge “organizes, conducts, controls, and manages the investigation” and “has the responsibility and authority to supervise and coordinate all resources and activities of all personnel, both Board and non-Board” involved in the investigation. 

Norfolk Southern knows this.

Norfolk Southern then went around the investigator-in-charge and our general counsel and sent the material directly to the Board Members — five presidentially-appointed, Senate confirmed government officials — via email on May 1st, urging us to overrule our investigator-in-charge and “direct” staff to include in our public docket Norfolk Southern’s party submission, which, they’d been told repeatedly violated our regulations. 

This demonstrated complete disregard for the conduct of our independent investigation. 

In speaking with the investigative and legal teams, Norfolk Southern’s abuse of the party process was reprehensible.

Two weeks ago, Norfolk Southern visited each of us. It is a normal part of the process, where parties are afforded the opportunity to meet with Board Members before a final Board meeting. 

In their meeting with me, with NTSB staff from the Offices of Railroads, Pipelines, and Hazardous Materials Investigations, General Counsel, and Safety Recommendations and Communications, one of Norfolk Southern’s senior executives stated that it was their hope that — in this Board meeting and the community meetings — the NTSB would put to rest the “rumor” that Norfolk Southern made the decision to vent and burn to move trains. 

That is not only unethical and inappropriate, but defending an entity’s decision-making is not our role. 

Norfolk Southern’s senior executive went on to say that there’s a “real interest” on the part of the Department of Justice and the Administration to move on — something I’ve never heard once from the Department of Justice or the Administration. 

Norfolk Southern then stated that this is an opportunity to close a chapter and allow the community and the railroad to move on. 

The entire exchange ended with what-everyone from the NTSB heard in the room was a threat — and it was delivered that way — to use every avenue and opportunity to vigorously defend their decision-making in media and hearings going forward. 

That is your right. But it’s not our role to defend Norfolk Southern; we’re here to protect the American people and the traveling public. Our entire mission centers around learning from the past and building a better, safer future for all. 

A few days ago, Norfolk Southern invited Board members to visit key areas near the derailment site as well as their new Digital Train Inspection portal in Leetonia, Ohio.

While site visits are wonderful educational opportunities, timing matters a great deal. 

As Federal officials, we must observe, among other standards, principles of ethical conduct. We must always perform our duties impartially and never create even an appearance of impropriety.

I believe this invitation…to visit Norfolk Southern the day before the Board meeting…would’ve indeed given the appearance of impropriety and, therefore, would’ve constituted a violation of our ethics standards. 

I struggled a lot with whether I wanted to share all this detail with the public as I don’t want it to overshadow our findings, probable cause, or safety recommendations that were issued today. 

But Norfolk Southern’s actions were unconscionable. I want everyone who works with the NTSB — on current and future investigations — to understand this: we are impervious to anything but the truth. 

We are the gold standard when it comes to accident investigation around the world; I will not allow any entity to impugn that reputation or malign the reputation of our investigative staff — our top-notch investigative staff. 

Today, I am initiating an internal effort with our Managing Director’s Office, the Office of General Counsel, and the investigative offices to evaluate our policies, our procedures, our Board Orders, and our regulations to ensure our agency, our people, and the work we do are adequately protected from undue interference with a federal investigation. 

I look at the staff before us today…and so many others who supported this investigation who are not here…I see dedicated public servants who are focused on doing what’s right.

I'm very proud of all you do — day in and day out, often getting up in the middle of the night, missing birthdays, holidays, graduations — to save lives. It is an honor — an honor — for each of us to serve alongside you. Thank you for all that you do. 

I’d like to extend the Board’s thanks to “Team NTSB,” our colleagues throughout the Office of Rail, Pipeline, and Hazardous Materials Investigations; the Office of Research and Engineering; and the Office of General Counsel for their work over the course of this investigation and in the development of an excellent report. 

We also express our appreciation to our colleagues in the Office of Human Capital Management and Training, the Office of the Chief Information Officer, and the Digital Services Division for their vital support of this meeting. 

I’d like to thank the Office of Safety Recommendations and Communications for its diligent work and advocacy to improve safety. And I’d like to thank our Office of Transportation Disaster Assistance who work with families and communities throughout the course of our investigations.

When acted upon, the recommendations we’ve issued today will save lives and prevent the next derailment and hazardous materials release. 

Going forward, the NTSB looks forward to working with the following organizations to implement our recommendations: 

  • ​The Secretary of Transportation; 
  • The Federal Railroad Administration;
  • The Pipeline and Hazardous Materials Safety Administration; 
  • The State of Ohio;
  • The Association of American Railroads;
  • The International Association of Fire Chiefs;
  • The International Association of Fire Fighters;
  • The National Volunteer Fire Council; 
  • The Chlorine Institute; 
  • OxyVinyls; 
  • The American Chemistry Council;
  • Norfolk Southern Railway; 
  • Columbiana County Emergency Management Agency; 
  • And the other Class I railroads.

  • ​At the same time, the NTSB will not stop working to create a safe transportation system where there is no longer a need for our recommendations. 

Be​fore I close, I first want to say thank you to somebody very special: Michael Hiller, Deputy Director of the NTSB’s Office of Railroad, Pipeline and Hazardous Materials Investigations.

This is Mike’s last Board meeting with us…at least for now; he’s always welcome back. 

Even though we’re incredibly sad to see him go, we are very excited for his new professional opportunity — an opportunity Mike made clear wouldn’t begin until after this Board Meeting because he wanted to see this investigation through to its conclusion. 

That’s not surprising to those of us who know Mike well: he’s incredibly dedicated to our mission.

Mike served as Chief Engineer for Rail Operations Delivery at the Washington Metropolitan Area Transit Authority…a role he held for 23 years prior to joining the NTSB.

Mike joined us in 2011 as a railroad accident investigator, where he led and supported numerous accident investigations involving both rail and pipeline transportation.

He served as the Investigator-In-Charge many times, including for several investigations that we’ve talked about today.

This includes the 2017 derailment of Amtrak passenger train 50 in DuPont, Washington, which, tragically, claimed three lives and left 65 other people injured. 

That investigation revealed significant communications issues among the response agencies…something that we also found here in East Palestine.

Mike was also the lead investigator following the 2017 derailment and hazardous materials release of a Union Pacific Railroad train in Graettinger, Iowa, where 322,000 gallons of ethanol were released. 

Under Mike’s leadership, we were able to determine that the continued use of DOT-111 tank cars contributed to the consequences of this accident…again, something we also found in this derailment. 

These are just two cases; I could go on. without a doubt, has contributed to innumerable rail, pipeline, and hazmat safety improvements that have saved lives and prevented countless injuries. 

So, on behalf of all of us, thank you, Mike for your service — both to this agency and the nation. 

The NTSB is incredibly lucky to have benefited from your leadership and expertise for the last 13-plus years. 

We will miss you; I certainly will miss you. 

Thank you. With that, we stand adjourned.

 ​​


​​​​​​