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Safety Recommendation Details

Safety Recommendation I-81-001
Details
Synopsis: ON APRIL 3, 1980, A BOSTON AND MAINE CORPORATION (BM) BOSTON SWITCHER (1740) CONSISTING OF A LOCOMOTIVE AND 38 CARS COLLIDED, WHILE MOVING AT A SPEED OF 4 MPH, WITH A STANDING DRAFT OF CARS IN SOMERVILLE YARD 8 AT SOMERVILLE, MASSACHUSETTS. THE LOCOMOTIVE STRUCK AND PUNCTURED TANK CAR TLDX 113009, THE SECOND CAR OF THE STADING DRAFT; THE TANK CAR CONTAINED ABOUT 13,000 GALLONS OF PHOSPHORUS TRICHLORIDE (PC13), A HAZARDOUS MATERIAL CLASSIFIED BY THE DEPARTMENT OF TRANSPORTATION (DOT) AS A CORROSIVE LIQUID. THE PRODUCT SPILLED ONTO THE MOIST GROUND AND CREATED A CLOUD, WHICH ULTIMATELY NECESSITATED AN EVACUATION OF A 1 1/2 SQUARE MILE AREA CONTAINING 23,000 PEOPLE. DURING THE FIRST 48 HOURS OF THE EMERGENCY, 418 PERSONS WERE TREATED AT THE SOMERVILLE HOSPITAL. DAMAGE TO TRAIN EQUIPMENT AMOUNTED TO $8,100 AND CLEANUP COSTS WERE REPORTED TO BE $130,253.
Recommendation: THE NTSB RECOMMENDS THAT THE DEPARTMENT OF TRANSPORTATION: INVESTIGATE THE ADEQUACY AND CONSISTENCY OF HAZARDOUS MATERIALS EMERGENCY GUIDES AND OTHER ADVICE AVAILABLE TO LOCAL OFFICIALS FOR USE IN CONTROLLING HAZARDOUS MATERIALS RELEASES DURING TRANSPORTATION, AND TAKE NECESSARY STEPS TO ASSURE THAT THEY PROVIDE SUFFICIENT AND CONSISTENT GUIDANCE AND ADVICE TO HELP LOCAL OFFICIALS CONTROL HAZARDOUS MATERIALS SPILLS QUICKLY AND EFFECTIVELY.
Original recommendation transmittal letter: PDF
Overall Status: Closed - Acceptable Action
Mode: Intermodal
Location: Somerville, MA, United States
Is Reiterated: Yes
Is Hazmat: No
Is NPRM: No
Accident #: 80175
Accident Reports: ​Phosphorus Trichloride Release in Boston and Maine Yard During Switching Operations
Report #: HZM-81-01
Accident Date: 4/3/1980
Issue Date: 3/12/1981
Date Closed: 4/25/1988
Addressee(s) and Addressee Status: RSPA (Closed - Acceptable Action)
Keyword(s): Hazmat

Safety Recommendation History
From: NTSB
To: RSPA
Date: 4/25/1988
Response:

From: RSPA
To: NTSB
Date: 2/2/1988
Response: THE DEPARTMENT'S RESPONSE TO THE RECOMMENDATION WAS REFLECTED IN ITS 1984 REVISION OF THE EMERGENCY RESPONSE GUIDEBOOK (ERG). THE ERG REPRESENTS POSSIBLY THE BEST "FIRST RESPONSE" ADVICE THAT EXISTS TODAY. PRIOR TO PUBLICATION OF EACH EDITION OF THE ERG, EXPERTS AND INTERESTED PARTIES FROM INDUSTRY, PROFESSIONAL ORGANIZATIONS, EMERGENCY RESPONSE ORGANIZATIONS, AND FEDERAL AGENCIES, PARTICIPATE IN MEETINGS CONDUCTED BY THE RESEARCH AND SPECIAL PROGRAMS ADMINISTRATION. THE ERG DOES NOT, HOWEVER, ATTEMPT TO ANTICIPATE ALL POSSIBLE VARIATIONS OF THOSE CONDITIONS. WE BELIEVE THAT THE ERG'S USEFULNESS AS A FIRST RESPONDER'S GUIDE WOULD BE GREATLY UNDERMINED BY ATTEMPTS TO TAILOR ADVICE FOR EVERY POSSIBLE COMBINATION. AFTER STUDYING THE MIAMISBURG ACCIDENT, THE SAFETY BOARD HAS REVERSED ITS EARLIER FINDING AND NOW CONCLUDES THAT THE DEPARTMENT HAS NOT ACCOMPLISHED THE IMPROVEMENTS SOUGHT BY RECOMMENDATION I-81-1. THE ERG IS INTENDED TO BE VERY SIMPLE TO USE BY THOSE RESPONDERS FIRST ON THE SCENE. THE INTRODUCTION TO THE 1984 EDITION OF THE ERG INCLUDED AN EXPLICIT QUALIFICATION. THIS QUALIFICATION, IS PARTICULARLY IMPORTANT BECAUSE IT PLACES ALL USERS ON NOTICE THAT THE ERG WAS NEVER INTENDED TO BE A SUBSTITUTE FOR INFORMED TECHNICAL ADVICE. THE ERG IS NOT CONSIDERED TO BE AN APPROPRIATE VEHICLE FOR ARTICULATING THE TECHNICAL REASONS FOR THE ADVICE GIVEN. THE INCLUSION OF TEXT EXPLAINING THE TECHNICAL REASONS FOR RECOMMENDED ACTIONS COULD CHANGE THE ERG FROM A GUIDEBOOK TO AN ENCYCLOPEDIA, THEREBY RENDERING IT USELESS FOR ITS INTENDED PURPOSE. THE DEPARTMENT PLACES GREAT IMPORTANCE ON ENSURING THE SAFE TRANSPORTATION OF HAZARDOUS MATERIALS. WE WILL CONTINUE TO MONITOR AND EVALUATE THE EFFECTIVENESS OF THE EMERGENCY RESPONSE GUIDANCE PROVIDED BY THE ERG.

From: NTSB
To: RSPA
Date: 9/29/1987
Response: From the hazardous materials accident report: Hazardous materials release following the derailment of Baltimore and Ohio Railroad Company train number SLFR in Miamisburg, Ohio on July 8, 1986. The Board adopted this report on 9/29/1987. As a result of its investigation of this accident, the National Transportation Safety Board reiterated Safety Recommendation I-81-1 to the Department of Transportation.

From: NTSB
To: RSPA
Date: 8/11/1982
Response:

From: RSPA
To: NTSB
Date: 7/6/1982
Response: DOT (RSPA) LTR: WITH RESPECT TO RECOMMENDATION I-81-1, THE SAFETY BOARD REQUESTED THAT IT BE "OFFICIALLY ADVISED OF ANY PROGRESS MADE BY THE REVIEW GROUP ON A QUARTERLY BASIS." THE REVIEW GROUP, WHICH IS AD HOC IN NATURE AND COMPOSED OF A FULL SPECTRUM OF REPRESENTATIVES FROM GOVERNMENT, THE INDUSTRY, AND PRIVATE CONSULTANTS, DOES NOT HAVE A FIXED SCHEDULE FOR MEETING. ON THE CONTRARY, THE MEETING OF THE REVIEW GROUP CAN BE CONVENED AT THE URGING OF STATE AND LOCAL GOVERNMENT, THE INDUSTRY, OR THE NTSB. THE NTSB WILL BE INFORMED OF EACH MEETING AS IT IS CALLED AND HAS A STANDING INVITATION TO ATTEND AND PARTICIPATE. WE BELIEVE THAT THIS APPROACH WILL BE MORE PRODUCTIVE THAN THE SUBMISSION OF QUARTERLY STATUS REPORTS TO THE NTSB. STEPS HAVE ALSO BEEN TAKEN TO ESTABLISH AND MAINTAIN CONSISTENCY IN THE EMERGENCY RESPONSE GUIDE MATERIALS. THE REVISIONS OF THE 1980 DOT EMERGENCY RESPONSE GUIDEBOOK BEING CONDUCTED BY JOHNS HOPKINS APPLIED PHYSICS LABORATORY IS TAKING PLACE SPECIFICALLY WITH REFERENCE TO THE CONTENT OF THE EMERGENCY RESPONSE GUIDEBOOKS AVAILABLE FROM THE BUREAU OF EXPLOSIVES AND THAT OF THE NATIONAL FIRE PROTECTION ASSOCIATION.

From: NTSB
To: RSPA
Date: 4/26/1982
Response:

From: RSPA
To: NTSB
Date: 12/4/1981
Response: RSPA LTR: NTSB WAS INVITED TO ATTEND A MEETING OF AN AD HOC REVIEW GROUP WHICH WAS ASSEMBLED TO REVIEW THE 1980 DOT EMERGENCY RESPONSE GUIDEBOOK. THE FIRST MEETING OF THE COMMITTEE WAS HELD ON SEPTEMBER 22, 1981. I-81-1 RECOMMENDED THAT DOT TAKE STEPS TO ENSURE THAT THE DOT EMERGENCY RESPONSE GUIDEBOOK PROVIDE PROPER GUIDANCE TO LOCAL OFFICIALS. THE DOT EMERGENCY RESPONSE GUIDEBOOK IS GENERIC IN NATURE AND IS DESIGNED FOR USE BY FIRST RESPONDERS TO A HAZARDOUS MATERIALS INCIDENT. THE GUIDELINES ARE INTENDED TO ADDRESS ONLY THE INITIAL PHASES OF AN EMERGENCY; WE INTEND TO REMOVE INSTRUCTIONS THAT DO NOT RELATE TO INITIAL PHASES. OUR ABILITY TO ENSURE THE ADEQUACY AND CONSISTENCY OF INFORMATION CONTAINED IN OTHER SOURCE MATERIALS RAISES A DIFFERENT ISSUE SINCE THE DEPARTMENT OF TRANSPORTATION HAS NO POWER TO COMPEL OTHER ORGANIZATIONS TO ISSUE THEIR EMERGENCY RESPONSE INFORMATION IN ACCORDANCE WITH OUR OWN GUIDELINES. HOWEVER, WE SHALL DO ALL WE CAN TO ENSURE CONSISTENCY BY CONTACTING OTHER ORGANIZATIONS WHICH ISSUE EMERGENCY RESPONSE GUIDES TO RESOLVE DISCREPANCIES BETWEEN OUR GUIDE AND THEIR GUIDES.