WASHINGTON - The National Transportation Safety Board (NTSB) today determined that the washout of a track structure and the failure to notify an oncoming train of the washout in time, caused the derailment of 19 cars. While the washout was discovered about an hour before the train's arrival, Canadian National Railway Company's (CN) inadequate emergency communication procedures prevented timely notification.
On June 19, 2009, an eastbound CN freight train traveling at 36 mph derailed at a highway/rail grade crossing in Cherry Valley, Illinois. The train consisted of two locomotives and 114 cars. All of the derailed cars were tank cars carrying ethanol, a flammable liquid. Thirteen of the derailed tank cars were breached or lost product and caught fire. At time of the derailment, several motor vehicles were stopped on either side of the grade crossing waiting for the train to pass. As a result of the fire that erupted after the derailment, a passenger in one of the stopped vehicles was fatally injured, two passengers in the same car received serious injuries, and five occupants of the other cars waiting at the highway-rail crossing were injured.
"There were missteps and miscommunications, procedures not followed and poor decisions," said NTSB Chairman Deborah A.P. Hersman. "There were multiple points where this catastrophe could have been averted, but it was not."
Contributing to the accident was CN's failure to work with Winnebago County to develop a comprehensive storm water management design to address previous washouts in 2006 and 2007. Also, contributing to the severity of the accident was CN's failure to issue a flash-flood warning to the train crew and the inadequate design of the tank cars, which made the cars subject to damage and catastrophic loss of hazardous materials during the derailment.
As a result of this accident investigation, the NTSB made safety recommendations to the U. S. Department of Transportation, Federal Railroad Administration, the Pipeline and Hazardous Materials Safety Administration, the Association of American Railroads, the National League of Cities, the National Association of Counties, the Association of State Dam Safety Officials, the National Association of Towns and Townships, the U.S. Conference of Mayors, and the Canadian National Railway Company.
The NTSB also made recommendations to American Association of State Highway and Transportation Officials, the National Association of County Engineers, the American Public Works Association, and the Institute of Transportation Engineers.
The safety issues addressed by the recommendations include: effective internal emergency communications, weather-alert policies and rules, tank-car vulnerabilities, inspection and maintenance of stormwater detention ponds, the accuracy of train consist information, construction standards for underground pipelines at railroad crossings, and the principles of Safety Management Systems.
A synopsis of the NTSB report, including the probable cause, conclusions, and a complete list of all the safety recommendations, is available at: http://www.ntsb.gov/news/events/2012/cherry_valley/index.html.
The NTSB's full report will be available on the website in several weeks.
NTSB Media Contact: NTSB Public Affairs Keith Holloway