WASHINGTON - The National Transportation Safety Board determined today the
probable cause of a derailment at Paulsboro Bridge in New Jersey, which resulted
in a hazardous material release. The derailment occurred because Consolidated
Rail Corporation rules allowed the train to proceed past a red signal onto a
movable bridge without the rail slide locks being fully engaged. Investigators
determined that Conrail relied on a training and qualification program that did
not prepare the train crew to adequately examine the bridge lock system.
Contributing to the accident was the lack of a comprehensive safety
management program. Such a program would have identified multiple bridge
malfunctions, which had been increasing in frequency, and mitigated the risks
associated with the continued operation of the bridge.
"The stakes are too high to leave multiple malfunctions uncorrected without a
robust process that adequately mitigates the increased risk," said Acting
Chairman Christopher A. Hart. "And that starts at the top. In this case, the red
signal was correct. Inadequate bridge inspection procedures – compounded by the
lack of a safety management system - were the problem."
On Friday, November 30, 2012, at 6:52 a.m., a Conrail freight train stopped
for a red signal at the Paulsboro movable bridge over the Mantua Creek in
Paulsboro, NJ. The signal indicated that the bridge was not secured for the
train to cross.
The train crew repeatedly sent a command to the bridge control system to
close and secure the bridge, in accordance with Conrail's procedure. The train
conductor told investigators that when the signal did not change from red to
green after several attempts, he visually inspected the bridge. The NTSB
investigation determined the conductor incorrectly concluded that it was safe to
proceed. The crew informed the train dispatcher that the bridge was safe to
cross, and requested permission, which the dispatcher granted.
Conrail's operating procedures allowed a train to proceed past a red signal
protecting a moveable bridge if (1) a qualified employee visually inspected the
bridge to ascertain that the running rails are aligned and locked, and (2) the
train dispatcher granted permission to proceed.
Investigators found that neither Conrail nor any regulator provided any
guidance regarding what constitutes a "qualified employee" for this situation,
making compliance difficult to ascertain. Further, Conrail employees did not
receive any formal training or written guidance on performing a movable bridge
While crossing the unlocked bridge, the bridge moved and seven cars derailed.
Four cars fell into the creek below, including three carrying vinyl chloride and
one carrying ethanol. One of the derailed tank cars was breached and released
approximately 20,000 gallons of vinyl chloride.
The NTSB's investigation revealed that the Paulsboro bridge had malfunctioned
23 times in the year before the accident, including 11 times in the final month
leading up to the derailment. Train crews had reported issues with the bridge
when attempting to cross.
A second focus of the report is the emergency response to the vinyl chloride
release. The incident commander did not follow established protocols to protect
workers and the community. The Conrail trainmaster did not immediately provide
the train consist, delaying the identification of the hazardous material
released. And, once the vinyl chloride was identified, the incident commander
did not instruct first responders to wear protective equipment or maintain a
safe distance from the accident site.
As a result of the investigation, the NTSB issued 20 safety recommendations.
They include a recommendation to the Federal Railroad Administration (FRA) to
issue a regulation for permitting a train to pass a red signal aspect at a
moveable bridge that is similar to the regulation for crossing a broken rail.
This would ensure that the bridge had been inspected by a qualified employee
before a train is authorized to proceed across the bridge.
The NTSB recommendations also address several issues with emergency response,
including failure to follow established hazardous materials response protocols
and inadequacies of emergency planning, emergency preparedness, and public
awareness for hazardous materials transported by train.
The NTSB reiterated a recommendation to the FRA to require railroads to adopt
safety management systems.
A synopsis of the NTSB report, including the probable cause, findings, and a
complete list of the safety recommendations, is available here
The full report will be available in several weeks.