Conrail Freight Train Derailment with Vinyl Chloride Release

Kyle Malec

3/17/15

Background

• Engineer: 51 years old, working with Conrail since 2003. 8 years of previous experience. Was current on 3-year locomotive certification license. No prior incidents.

• Conductor: 42 years old, working with Conrail since 2008. Promoted to conductor in 2009 after completing training program. Two 30-day suspensions from operating violations and one 10-day for the same offense.

• Train Dispatcher: 53 years old, working with Conrail since 1994, became dispatcher in 1996. No prior incidents.

Background cont.

• Occurred on November 30, 2012 in Paulsboro, New Jersey.

• A red signal aspect was displayed and did not change to green when the radio signal command was executed by the train crew, indicating that the bridge was not prepared for train movement.

• The conductor inspected the bridge and erroneously concluded it was properly locked to prevent movement.

• The engineer informed the dispatcher of the conductor’s findings. The dispatcher then gave permission for the train to pass the red signal aspect and cross the bridge, as allowed by Consolidated Rail Corporation operating rules and procedures.

Background cont.

• As the train traveled across the bridge, 7 cars derailed, the 6th through the 12th cars.

• Physical evidence indicated that the swing span locking mechanism was not engaged at the east end of the bridge.

• The bridge span rotated under the moving train, misaligned the running rails, and caused the train to derail.

• The bridge was structurally sound and did not collapse.

Background cont.

• Three of the derailed tank cars that entered the creek contained vinyl chloride and one contained ethanol.

• One tank car was breached and released about 20,000 gallons of vinyl chloride. Eyewitnesses reported a vapor cloud engulfed the scene immediately following the accident.

• On the day of the accident, 28 area residents sought medical attention for possible vinyl chloride exposure. The train crew and numerous emergency responders were also exposed to vinyl chloride.

• Equipment damage estimates were $451,000. The emergency response and remediation costs totaled about $30 million.

NTSB Conclusion

• The NTSB concluded that the probable cause of the accident to be:

• 1. Allowing the train to proceed past the red signal aspect with the rail slide locks not fully engaged allowing the bridge to move.

• 2. Having to rely on the training and qualifications program that had not prepared the train crew for this type of situation.

Factors

• Improper/Lack of Training

• Arrogance from the Supervisor in terms of ignoring red flags.

Solutions

• Providing the Proper Training

• Hiring Correctly (inspector)

• Bridge Preservation Program

• Adding Regulations

Conclusion

• Completely avoidable, plain and simple.

References

• http://www.ntsb.gov/investigations/AccidentReports/Reports/RAR1401.pdf

• http://www.ecfr.gov/cgi-bin/text-idx?SID=6a6092ff88cf68882ce0b15790147a0f&node=se49.4.237_131&rgn=div8

• . http://www.rssb.co.uk/Library/improving-industry-performance/2008-guide-understanding-human-factors-a-guide-for-the-railway-industry.pdf

• http://www.ecfr.gov/cgi-bin/text-idx?SID=89e592bcfbef8fbc254b1308fa59cdaa&node=se49.4.237_153&rgn=div8