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NTSB PRESS RELEASE
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National Transportation Safety Board
Washington, DC 20594
FOR IMMEDIATE RELEASE: May 13, 2008
SB-08-19
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NTSB DETERMINES INADEQUATE RAIL INSPECTION CAUSED 2006
PENNSYLVANIA DERAILMENT
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Washington, DC -- The National Transportation Safety Board
determined today that the probable cause of the derailment
of a Norfolk Southern Railroad Company train was the
railroad's inadequate rail inspection and maintenance
program that resulted in a rail fracture from an undetected
internal defect. Contributing to the accident was the
Federal Railroad Administration's inadequate oversight of
the internal rail inspection process and its insufficient
requirements for internal rail inspection.
On Friday, October 20, 2006, a Norfolk Southern freight
train (68QB119), en route from the Chicago, Illinois area to
Sewaren, New Jersey, derailed while crossing the Beaver
River railroad bridge in New Brighton, Pennsylvania. The
train consisted of a three-unit locomotive pulling three
empty freight cars and 83 tank cars loaded with 660,952
gallons of denatured ethanol. Twenty-three of the tank cars
derailed. Several of the cars fell into the Beaver River.
Approximately 20 of the cars released ethanol, a flammable
liquid that ignited and burned for 48 hours. A seven-block
area of New Brighton was evacuated. There were no injuries
or fatalities.
"Because Norfolk Southern did not have an adequate rail
inspection and maintenance program, they put the public,
crew, and environment at risk," said NTSB Chairman Mark V.
Rosenker.
The track where the derailment occurred was installed in
1977 and had experienced significant rail head wear prior to
the accident. Norfolk Southern had hired a contractor to
inspect the track for internal rail defects. In 2006, three
ultrasonic/induction inspections for internal rail defects
were conducted on the accident track. The last inspection
on August 1, showed an intermittent loss of bottom signal
over a 9-foot length of rail in the area where the
derailment subsequently occurred.
FRA regulations require that all railroads conduct a
continuous search when inspecting rail for internal defects.
Additionally, according to the FRA, any rail inspection
that is interrupted, as a result of rail surface conditions
that inhibit the transmission or return of the signal, is
not considered to be continuous and therefore is not
considered a valid inspection of the affected rail segment.
However, about a year and a half before the accident and
without consulting the FRA, Norfolk Southern gave new
procedures to the inspection contractor for inspecting rail
for internal defects. The procedures permitted inspection
equipment operators to ignore any loss of bottom signal, as
long as the continuous loss of signal distance did not
exceed 5 feet of linear rail. The Safety Board
investigation found that the initiating defect that caused
the rail fracture was located in the length of rail that had
the loss of bottom signal during the August 1 inspection.
The equipment operator did not stop the inspection vehicle
for a re-inspection or to hand inspect the rail, consistent
with the procedures provided by Norfolk Southern.
"Norfolk Southern was not conducting a continuous search of
their rail for internal defects, which left segments of rail
uninspected and in service indefinitely," Rosenker said.
"This accident illustrates the importance of having a
comprehensive rail inspection and maintenance program that
will account for factors such as rail head wear and loss of
signal during internal testing."
As a result of this accident, the Safety Board made the
following recommendations:
To the Federal Railroad Administration:
1. Review all railroads' internal rail defect
detection procedures and require changes to those
procedures as necessary to eliminate exceptions to
the requirement for an uninterrupted, continuous
search for rail defects.
2. Require railroads to develop rail inspection and
maintenance programs based on damage-tolerance
principles and approve those programs. Include in
the requirement that railroads demonstrate how
their programs will identify and remove internal
defects before they reach critical size and result
in catastrophic rail failures. Each program should
take into account, at a minimum, accumulated
tonnage, track geometry, rail surface conditions,
rail head wear, rail steel specifications, track
support, residual stresses in the rail, rail defect
growth rates, and temperature differentials.
3. Require that railroads use methods that accurately
measure rail head wear to ensure the deformation of
the head does not affect the accuracy of the
measurements.
4. Assist the Pipeline and Hazardous Material Safety
Administration in its evaluation of the risk posed
to train crews by unit trains transporting
hazardous material, determination of the optimum
separation requirements between occupied
locomotives and hazardous material cars, and any
resulting revision of 49 Code of Federal
Regulations 174.85.
To the Pipeline and Hazardous Materials Safety
Administration:
5. With the assistance of the Federal Railroad
Administration, evaluate the risk posed to train
crews by unit trains transporting hazardous
materials, determine the optimum separation
requirements between occupied locomotives and
hazardous material cars, and revise 49 Code of
Federal Regulations 174.85 accordingly.
To Norfolk Southern:
6. Revise your ultrasonic rail inspection procedures
to eliminate exceptions to the requirement for
uninterrupted, continuous search for rail defects.
A synopsis of the Board's report, including the probable
cause and recommendations, is available on the website,
www.ntsb.gov, under Board Meetings. The full report will be
available on the website in several weeks.
-30-
Media Contact: Terry N. Williams, 202-314-6100
williat@xxxxxxxx
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