​​Good morning, Chair Cantwell, Ranking Member Cruz, and members of the Committee. Thank you for inviting the National Transportation Safety Board (NTSB) to testify on improving rail safety in the aftermath of the Norfolk Southern Railway (NS) freight train derailment and the subsequent release of hazardous materials in East Palestine, Ohio.

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 cause of the accidents and events we investigate and issue safety recommendations aimed at preventing future accidents and events. In addition, we conduct transportation safety research studies and offer information and other assistance to family members and survivors for any accident investigated by the agency. We also serve as the appellate authority for enforcement actions involving aviation and mariner certificates issued by the Federal Aviation Administration (FAA) and the United States Coast Guard, and 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 transportation safety through our 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 tragedies and injuries and save lives.

First and foremost, I want to thank each of you for your partnership with the NTSB to improve safety across all modes of transportation, including rail safety. I commit to you, the people of East Palestine, and all others who were affected in Ohio, Pennsylvania, and West Virginia, that the NTSB will conduct a thorough, independent, and transparent investigation into how this event occurred. We will examine the derailment, fire, hazardous materials release, and the emergency response in the hours and days after the derailment, and we will make recommendations that, if acted on, will prevent other communities from suffering a similar tragedy.

Despite recent accidents, I want to be clear that rail remains one of the safest means of transportation. For transport of some classes and quantities of hazardous materials, there is no safer alternative. Certainly, carrying them over our nation’s roadways where more than 43,000 people die every year in millions of crashes is not a safer alternative. Moreover, such small quantities of hazardous materials shipped by rail may not be economically feasible for pipeline operators to ship.

For communities that are impacted by rail accidents, particularly involving hazardous materials, I know that is little consolation as just one derailment, as we have seen in East Palestine, can be devastating. I also want to be clear that there is work that can be done to further improve rail safety, related to East Palestine and aside from our investigation. The NTSB has over 180 rail safety recommendations that are currently open.[1] These include 5 recommendations to the U.S. Department of Transportation (DOT), 80 recommendations to the Federal Railroad Administration (FRA), and 9 recommendations to the Pipeline and Hazardous Materials Safety Administration (PHMSA). The safety issues we see in our investigations are tragic because they are preventable, and therefore should be acted on. ​

The Derailment

Our preliminary report on the derailment, issued on February 23, 2023, summarizes the factual information that was collected during the on-scene portion of our investigation.[2]

On Friday, February 3, 2023, NS freight train 32N, comprised of two head-end locomotives, 149 railcars, and 1 distributed power locomotive, was traveling east on the Fort Wayne Line of the Keystone Division. The consist included 20 placarded hazardous materials tank cars transporting combustible liquids, flammable liquids, and flammable gas, including vinyl chloride; 17 of these were fully loaded, 3 were residue cars. The train crew consisted of an engineer, conductor, and conductor trainee.

NS had equipped its rail network on that line with hot bearing detectors (HBDs) to assess the temperature conditions of wheel bearings while trains are en route. When the HBD detects overheated bearings, it provides an audible, real-time warning to train crews. According to NS’s criteria, a reading above 200°F triggers a critical alert.

Train 32N passed three HBD systems in the last 30 miles before the derailment. About 30 miles before the derailment, a wheel bearing from the 23rd car was recorded at 38°F above ambient temperature (about 10°F at the time). When the train passed the next HBD about 10 miles later, the bearing’s recorded temperature was 103°F above ambient temperature. The third HBD, about 20 miles later, recorded the bearing’s temperature at 253°F above ambient temperature and sent a critical alert to the crew to stop the train and inspect the axle.

At the time, the engineer was already slowing the train because there was another train ahead. Once the critical alert was received, he increased the brake application to further slow and stop the train. During the deceleration, the wheel bearing on the 23rd car failed and the car derailed, resulting in an emergency brake application stopping the train. After the train stopped, the crew observed fire and smoke, and reported a possible derailment to the NS train dispatcher. Responders arrived at the derailment site and began response efforts. ​

A total of 38 railcars derailed, 11 of which were carrying hazardous materials. The combination of the plastic pellets in the 23rd car and the hot axle of that car likely started the initial fire. First responders implemented a 1-mile evacuation zone surrounding the derailment site, affecting up to 2,000 residents.

On February 5, responders mitigated the fire, but five derailed tank cars, carrying a total of 115,580 gallons of vinyl chloride, continued to concern authorities. The temperature inside one tank car was still rising, which suggested that the vinyl chloride was undergoing polymerization, a chemical chain reaction that could pose an explosion hazard. Responders scheduled a controlled venting of the five vinyl chloride tank cars to release and burn the vinyl chloride. They expanded the evacuation zone to a 1-mile by 2-mile area and dug ditches to contain released vinyl chloride liquid while it vaporized and burned. The controlled venting began about 4:40 p.m. on February 6 and continued for several hours. The NTSB had no role in the decision to vent and burn the five vinyl chloride tank cars; however, we will evaluate that decision and the process for carrying out the vent and burn in our investigation.

NTSB’s Response and Investigation

Each of the NTSB’s investigative offices assigns a duty officer who is on call 24/7 to receive notifications of accidents and incidents, gather pertinent information, and make a recommendation as to whether the event meets the criteria for launching an investigation. The duty officer for the NTSB’s Office of Railroad, Pipeline, and Hazardous Materials Investigations (RPH) was first contacted about the derailment on February 3 at about 10:00 p.m. and began collecting initial information, including contacting NS. At 10:53 p.m., the National Response Center (NRC) received a report on the derailment.[3] At 11:16 p.m., the NRC formally notified the NTSB’s Response Operations Center of the derailment. From the time of notification and throughout the night, NTSB staff worked to collect and assess information from industry, labor, emergency responders, and others on the scene to determine whether to launch an investigation.

At about 12:00 a.m., the RPH duty officer, having obtained sufficient information, informed the director of RPH, who, by regulation, is authorized to initiate an investigation.[4] RPH notified NS, the FRA, and the railroad unions that the NTSB would be investigating. This notification to NS also served as an order to preserve evidence. ​

Following these calls, the RPH director requested a call with agency leadership to discuss whether a Board member should launch to the accident, as well as to determine any additional resource needs. Board members are typically launched on major investigations and act as the spokesperson on scene. At 7:15 a.m., the determination was made to launch the on-duty Board member, Michael Graham, and a full “go-team” of 14 NTSB staff members. Member Graham and the initial responding staff departed at 11:30 a.m. and began arriving in East Palestine at 1:30 p.m.

While on scene, investigators examined railroad equipment and track conditions; reviewed data from the signal system, wayside defect detectors (including the HBDs), local surveillance cameras, and the lead locomotive’s event recorder and forward- and inward-facing image recorders; and conducted interviews. The wheel bearing and affected wheelset from the 23rd car have been collected as evidence and will be examined in our laboratories in Washington, DC.

Investigators returned to Ohio on February 21 to examine each hazardous material tank car, document damage, and secure evidence for laboratory analysis. The vinyl chloride tank car top fittings, including the pressure relief devices (PRDs), were examined on scene. The top fittings were shipped to Texas for testing under the supervision, direction, and oversight of the NTSB.

Testing of the PRDs and angle valves was carried out the week of March 13. The testing was intended to determine if the valves still function in the as-received condition and to what level; document any foreign matter fouling, and document what fire/heat damage occurred with photographs and test forms on condition. Following testing, the valves and PRDs were disassembled, and the conditions of the parts were documented and photographed. Investigators found that further metallurgical testing of the PRDs and valves, including valve stems, is warranted to evaluate their performance and compatibility with the vinyl chloride lading. This testing will be conducted at the NTSB’s laboratory.

While on scene, Member Graham hosted two press briefings to provide updates regarding the status of our investigation: one on February 4 and another on February 5. The briefings, additional videos of the scene, and all investigative updates are available on our website.[5]

For the on-scene and continued fact-finding phase of this investigation, we have designated regulators, the carrier, shippers, manufacturers, workers, and first responders with relevant information as parties to the investigation. These parties provide the agency with technical expertise. This party system process has been our practice for decades because it is the most effective way to investigate major transportation accidents. The party system also ensures that the appropriate regulatory agencies and the parties whose products or services were involved in the accident or incident will have access to factual information, so they can initiate any necessary safety actions without delay. For this investigation, the parties are the PHMSA; the FRA; the Ohio State Highway Patrol; the Village of East Palestine; NS; Trinity Industries Leasing Company; the GATX Corporation; Midland Manufacturing; Occidental Chemicals, the Brotherhood of Railway Carmen; the International Association of Sheet Metal, Air, Rail and Transportation Workers; the Brotherhood of Locomotive Engineers and Trainmen; and the International Association of Firefighters. ​

Our investigation is ongoing. Future investigative activity will focus on the wheelset and bearing; tank car design and derailment damage; performance of PRDs and other valves; a review of the accident response, including the venting and burning of the vinyl chloride; railcar design and maintenance procedures and practices; NS’s use of wayside defect detectors; and NS’s railcar inspection practices.

Investigative Hearing

To support our investigation, we plan to hold an investigative field hearing in East Palestine in June. NTSB’s investigative hearings have four goals: to inform the public, to collect factual information from witnesses, to discuss possible solutions, and to build consensus for change. An investigative hearing will allow us to gather sworn testimony from witnesses on issues identified by the investigative team for this accident. The hearing will be wholly fact-finding in nature and open to the public; it will be preceded by a town hall for the public to provide comments to the NTSB.

Special Investigation into Norfolk Southern Railway's Safety Practices and Culture

On March 7, we announced a special investigation of NS’s organization and safety culture. Given the number and significance of recent NS accidents, we also urged the company to take immediate action to review and assess its safety practices, with the input of employees and others, and implement necessary changes to improve safety. We are undertaking this special investigation because, since December 2021, we have launched investigation teams to six significant accidents involving NS. We are concerned that several organizational factors may be involved in the accidents, including safety culture.

The NTSB has long recommended the implementation of safety management systems (SMS) in all modes of transportation. SMS is a systematic approach to managing safety, including the necessary organizational structures, accountabilities, policies, and procedures. An effective SMS program can help companies reduce and prevent accidents and accident-related loss of lives, time, and resources. Currently, there are a number of industry sectors worldwide that have recognized the benefits of effective safety management, including aviation and the maritime and pipeline communities. ​

The Rail Safety Improvement Act of 2008 (P.L. 110-432) required each Class I railroad to develop and implement a risk reduction program. In 2012, we recommended that FRA require that SMS and the associated key principles (including top-down ownership and policies, analysis of operational incidents and accidents, hazard identification and risk management, prevention and mitigation programs, and continuous evaluation and improvement programs) be incorporated into railroads’ risk reduction programs.[6] FRA issued the Risk Reduction Program (RRP) final rule on February 18, 2020, which includes the key principles recommended. We have since recommended that the FRA review all railroads’ RRP plans to ensure effectiveness and safety. Safety Recommendation R-12-3 is currently classified as “Open—Acceptable Response.” However, to date, no RRPs have yet been approved by FRA and implemented by the freight railroads. The NS derailments may provide a good opportunity for FRA to do so, as the recommendation remains open.

Continued Issues in Rail Safety

Although this investigation is ongoing, we have identified issues in several areas where the NTSB has previously made recommendations to improve safety.

Rail Tank Car Safety

Rail tank cars are built to certain DOT or industry specifications.[7] DOT-111 tank cars are non-pressurized tank cars with a thinner shell (7/16 in.) than is now required for DOT-117 tank cars (9/16 in.). These tank cars can carry both hazardous and non-hazardous liquids. DOT-111s are not required to have head shields to protect the tank car from an adjacent car in an incident. The top fittings and valves are not protected and are vulnerable to being sheared off in an incident, leading to a release of contents. These tank cars also do not have a pressure relief device sized to protect against rupture in the event of a large fire. DOT-111s do have pressure relief valves that offer some protection in some fires.[8]

​Fixing America’s Surface Transportation (FAST) Act (P.L. 114-94) phased out legacy DOT-111 specification tank cars for transporting Class 3 flammable liquids, such as crude oil, and the cars continue phasing out service for certain other commodities, such as ethanol. By May 1, 2023, nonjacketed and jacketed DOT-111 tank cars must be phased out; nonjacketed CPC-1232 tank cars must be phased out by July 1, 2023; and jacketed CPC-1232 tank cars must be removed or retrofitted by May 1, 2025. Each of those tank cars must be either removed from flammable liquids service or retrofitted with prescribed protective features, such as a head shield, jacket, and thermal protection. Other flammable liquids may not be transported in such tank cars beginning May 1, 2029.

In the East Palestine derailment, 13 of the 16 DOT-111s transporting hazmat that were damaged are not covered under the current DOT phaseout schedule. One of the three cars that would be covered by the current 2029 deadline breached. The other 13 DOT-111 cars sustained damage we’ve noted in other accident investigations but would not be covered under the FAST Act or DOT’s final rule.[9]

The NTSB has pointed out the inadequacy of DOT-111 tank cars for all hazardous materials, including flammable materials, since 1991, and we recommended they be replaced or retrofit in 2015.[10] The NTSB supports a shorter timeline to transition away from DOT-111s than what is currently in statute and regulation. Additionally, Congress should consider transitioning all other DOT-111s out of hazmat service.

The five derailed railcars carrying vinyl chloride were DOT-105 specification tank cars, which are used to transport liquified compressed gases, poison/toxic inhalation hazard materials, reactive materials, and/or corrosive materials requiring additional protection. None of these cars were breached in the derailment. However, we are currently evaluating the performance of the PRDs and valves.

When a tank car is exposed to fire conditions and its contents are heated, the pressure inside the tank rises. This can lead to loss of tank shell strength and eventually a breach. To protect emergency responders and the public from the possibility of catastrophic tank failure under fire conditions, the pressure inside tank cars must be controlled. PRDs are intended to regulate internal pressure by releasing material and reclosing after normal conditions are restored. This reduces the probability of a breach in the tank shell and limits the amount of energy a breach can release if one occurs. Properly functioning PRDs thus reduce the potential for catastrophic tank failure.

​Notification to Emergency Responders

Emergency responders must have real-time awareness of and information on the hazardous materials being transported by rail through their communities so that they are well prepared should an accident occur. We first made this recommendation 16 years ago.[11] Additionally, 9 years ago we recommended that railroads should help communities develop emergency operations and response plans.[12] The FAST Act also addressed this issue in 2015, but limited emergency responder awareness of and information on hazardous materials being transported by rail to high-hazard flammable trains (HHFTs), defined as a single train transporting 20 or more tank cars loaded with a Class 3 flammable liquid in a continuous block (a unit train) or a single train transporting 35 or more tank cars loaded with a Class 3 flammable liquid throughout the train consist.[13] Although PHMSA and the DOT have taken some actions, we remain concerned that emergency responders are not adequately made aware of hazardous materials traveling through their locations, and that current rules do not include a vast number of hazardous materials beyond combustible liquids.

The train in the East Palestine derailment was not a HHFT because it did not contain a block of 20 or more than 35 total loaded tank cars of a Class 3 flammable liquid.[14] We believe the definition of an HHFT should include a broad range of hazardous materials, including flammable gases and combustible liquids.[15]

We also believe that even one railcar of any hazardous material justifies notifying emergency responders, not 20 or more than 35 loaded tank cars, which could contain 1 million gallons of hazardous materials. Such thresholds present an unreasonable risk to public safety as a catastrophic derailment involving even a single tank car loaded with hazardous material can cause extensive destruction and loss of life. Therefore, we believe that the notification threshold should be significantly lower. In addition, the threshold should be based on the worst-case consequences of a derailment resulting in fire.

Recorders

Recorders—data, audio/voice, and video—are essential for capturing and storing critical information that can help investigators determine the cause of a transportation accident. Inward- and outward-facing recorders with both image and audio capabilities can increase the understanding of the circumstances of an accident, and, ultimately, provide greater precision in safety recommendations and subsequent safety improvements. ​

In the East Palestine accident, the locomotive was equipped with an inward- and forward-facing recorder. However, since NS put the locomotive immediately back in service following the accident, data was overwritten and only provide about 15 minutes of data before and 5 minutes following the derailment.

We use recorder data to determine the probable cause of accidents and to develop recommendations to help prevent future accidents. For example, after the December 18, 2017, derailment of National Railroad Passenger Corporation (Amtrak) train 501 in Dupont, Washington, investigators used event recorder data to derive the engineer’s actions prior to the crash.[16] Because of Amtrak 501’s inward-facing video and audio, investigators were able to determine that brief conversations between the engineer and the conductor during the trip did not distract them from their operational duties. This accident has demonstrated the value of image and audio data for the accident investigation and development of safety recommendations.

In contrast, during our investigation of the August 12, 2019, collision between two CSX trains in Carey, Ohio, our investigators did not have important information to assist in understanding what happened in this collision due to the lack of inward-facing video and audio recorders.[17] Because the FRA has not required inward-facing cameras for freight locomotives, the NTSB was unable to determine the actions of the westbound train’s crewmembers while operating the train from Columbus, Ohio, to Carey, Ohio, the actions of the westbound train engineer while operating alone in the locomotive cab, or the events leading up to the collision.

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. In 2010, we recommended that the FRA require the installation, in all controlling locomotive cabs and cab car operating compartments, of crash- and fire-protected inward- and outward-facing audio and image recorders capable of providing recordings to verify that train crew actions are in accordance with rules and procedures that are essential to safety as well as train conditions. The devices should have a minimum 12-hour continuous recording capability with recordings that are easily accessible for review, with appropriate limitations on public release, for the investigation of accidents or for use by management in carrying out efficiency testing and systemwide performance monitoring programs. ​[18] The recommendation to FRA is currently classified as “Open—Unacceptable Response.”

In the 13 years since this recommendation was issued, we have reiterated it in the six other major railroad investigations:

1. ​September 30, 2010, collision of two Canadian National Railway freight trains near Two Harbors, Minnesota;
2. April 17, 2011, collision of a BNSF coal train with the rear end of a standing BNSF maintenance-of-way train in Red Oak, Iowa;
3. June 24, 2012, head-on collision of two Union Pacific Railroad freight trains near Goodwell, Oklahoma;
4. May 25, 2013, collision of a Union Pacific Railroad freight train with a BNSF Railway freight train near Chaffee, Missouri;
5. April 28, 2015, collision of two Southwestern Railroad freight trains near Roswell, New Mexico; and
6. 6. May 12, 2015, derailment of a National Railroad Passenger Corporation (Amtrak) passenger train in Philadelphia, Pennsylvania.
   

Rail Worker Safety

Improving Rail Worker Safety is one of the issues highlighted in our 2021–2023 Most Wanted List of Transportation Safety Improvements.[19] Improving rail worker safety means making sure that roadway workers have the training, equipment, rest, and layers of protection they need while working on or around tracks. It means making sure that crews operating trains carrying hazardous materials have time to escape in case of an accident. It also means reducing the risks of derailments and collisions as trains become longer and heavier.

In recent years, we have investigated several railroad and transit accidents where workers have been struck and injured or killed while conducting routine maintenance or switching operations. Other workers are vulnerable when cars carrying hazardous materials are too close to those carrying train crew. We have also investigated accidents where crew have been killed riding on the sides of trains, in violation of rules.

On December 8, 2021, an employee for National Salvage and Service Corporation assigned to work with a NS work gang replacing track was killed when the operator of a spike machine reversed direction and struck the employee in Reed, Pennsylvania. The employee was marking rail to be removed and collected by the NS work gang when he was struck.

​On December 13, 2022, NS trainee conductor was killed, and another conductor injured, when their locomotive struck a length of steel angle iron protruding from a gondola car on a NS freight train that was stopped on an adjacent main track in Bessemer, Alabama. The angle iron originally welded to the gondola’s top-right edge was broken and hanging loose. As the locomotive approached the gondola car, it collided with the angle iron which then pierced the locomotive’s left front door window, continued into the operating cab, and struck both conductors.

On March 7, 2023, a NS conductor was killed when the train he was riding collided with a dump truck as they simultaneously entered a private highway–railroad grade crossing in the Cleveland-Cliffs Incorporated steel plant in Cleveland, Ohio. 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.

These three investigations are currently ongoing and will be part of our special investigation of NS’ organization and safety culture.

Although rail worker fatalities have declined overall in recent years, we continue to see recurring safety issues in our accident investigations that are 100 percent preventable, highlighting the need to implement our safety recommendations for better worker protections.[20]

NTSB’s Mandate and Resources

The NTSB’s authorization expired at the end of last fiscal year. As you know, we have sent Congress a reauthorization proposal that requests resources and hiring flexibility to increase the number of investigators in our Rail, Pipeline, and Hazardous Materials Investigations office, as well as in our other modes.[21] These resources will allow us to hire professionals with the needed skills, purchase the equipment necessary for those skilled professionals to do their jobs, and invest in staff training and development. Our workforce is our greatest asset and is essential to our mission.

The NTSB is required to investigate any railroad accident in which there is a fatality or substantial property damage, or that involves a passenger train.[22] We must currently meet this mandate with only 12 railroad investigators, 3 of whom are eligible for retirement, and 3 hazardous materials investigators. Those investigators are currently working on 28 investigations, and we open about 11 new investigations each year. This office is understaffed. In fact, as part of our reauthorization propos​al, we identified a need for 21 additional staff over the next 5 years. Our reauthorization request only fills a portion of this need. ​

Conclusion

The NTSB was on the ground in East Palestine on the first day following the derailment, and we are committed to finding out what happened, how it happened, and how to make sure that it never happens again.

The NTSB stands ready to work with the Committee to continue improving rail safety. Thank you again for the opportunity to testify today. I am happy to answer your questions.

​​1 A report of all currently open safety recommendations related to rail is available at