Kyle Malec

Railway Transportation Research Paper

Conrail Freight Train Derailment with Vinyl Chloride Release

Tech 438

3/6/15

EXECUTIVE SUMMARY

“On Friday, November 30, 2012, southbound Consolidated Rail Corporation freight train

FC4230, arrived and stopped on the main track at the Paulsboro moveable bridge near milepost

13.7 on the Consolidated Rail Corporation Penns Grove Secondary Subdivision 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. One of two conditions were required before the train could safety begin movement

over the bridge: The signal aspect changed to green, indicating that the running rails were

aligned and locked to the fixed track and both ends of the bridge, or the bridge was visually

inspected by a qualified employee to ascertain that the running rails were aligned and locked to

the fixed track at both ends of the bridge and permission was granted by the train dispatcher for

the train to pass the red signal. Despite multiple attempts by the train crew to remotely execute a

radio signal command to align and lock the bridge, the signal aspect remained red and did not

turn green. 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. As the train traveled

over 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. Four tank cars that derailed on the bridge

came to rest partially in Mantua Creek. 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 (NTSB1 2014).”

PROBABLE CAUSE

“The National Transportation Safety Board determines that the probable cause of the

derailment and subsequent hazardous material release at the Paulsboro moveable bridge was

Consolidated Rail Corporation (1) allowing the train to proceed past the red signal aspect with

the rail slide locks not fully engaged, which allowed the bridge to rotate and misalign the running

rails as the train moved across it, and, (2) relying on a training and qualification program that did

not prepare the train crew to examine the bridge lock system. Contributing to the accident was

the lack of a comprehensive safety management program that would have identified and

mitigated the risks associated with the continued operation of the bridge despite multiple bridge

malfunctions of increasing frequency. Contributing to the consequences of the accident was the

failure of the incident commander to implement established hazardous materials response

protocols for worker protection and community exposure to the vinyl chloride release (NTSB1

2014).”

PURPOSE

The purpose of this research paper is to examine the cause(s) of this selected

accident and determine solutions to prevent this type of event from ever occurring again. The

research will consists of possible human factors that may have contributed to the end result of an

accident, which were determined by the NTSB. Once the factors are determined, the proper steps

to be taken to ensure incidents of this caliber are no longer a possibility.

To start off, in the NTSB accident report, there were a list of factors that they determined

were not a contributing factor to the accident. “These included the weather conditions, the

engineer and conductor being under the influence of and substances, the locomotives and train

cars having defects, the tracks were free of any defects as well as measured the track geometry

and found no means of fault, the structural integrity of the bridge, the bridge control system and

the bridge signal system (NTSB2 2014).” In regards to the actual cause of this accident, it was

determined that the locks were not engaged which would of allowed the bridge allowing it to

move while the train traveled across it. “The train crew told NTSB investigators that the

conductor visually confirmed that the slide locks were locked before the train moved onto the

bridge. However, the post-accident examination determined that the east end slide locks were not

engaged, meaning the slide locks did not span the rail gap. Therefore, the NTSB concludes the

recorded data and post-accident physical condition of the slide lock components indicate that the

slide locks were not engaged on the east end of the bridge and the slide locks on the west end

were only partially engaged as the train crossed the bridge (NTSB2 2014).” With the information

provided by the NTSB investigators, possible human factors can be sought after to determine

which, if any, are responsible for the derailment.

One of the most common human factors that workers can be subjected to is

fatigue. Fatigue can occur when an employee is overtired or overworked to a point where all that

they can focus on is when they get to bed, allowing important duties of theirs or activities of

others go on without considering the risks of the actions being taken. When the accident

occurred, both the engineer and conductor were asked about how much sleep they both had at the

time of the accident. “The engineer had slept 6.5 hours the night before the accident and reported

for duty at 3:00 am. However, the information obtained for the engineer is insufficient to

determine whether fatigue was a factor in the accident (NTSB2 2014).” “The conductor had slept

between 6 and 7.5 hours the night before the accident and reported to duty at 3:00 am. However,

the information obtained for the engineer is sufficient to determine whether fatigue was a factor

in the accident (NTSB2 2014).” Based on these findings, although they were insufficient, that

fatigue may not have been a factor of the derailment.

Adding to that, another human factor that could have contributed towards the derailment

is that there was a lack of training and familiarity of the bridges mechanics. From the report, the

conductor had explained how he inspected the bridge on the day of the accident. “The conductor

also testified that he had inspected a moveable bridge on only one previous occasion, when a

more experienced conductor showed him the Paulsboro moveable bridge slide locks during on-

the-job training in 2009. Other than that, the accident conductor had not received any formal or

informal training, nor had he inspected any other bridge locking devices until moments before

the accident. The conductor’s lack of familiarity with the bridge locking mechanism was evident

when he was shown photographs of the equipment and testified that he was uncertain about the

distance the slide locks needed to extend for full engagement (NTSB2 2014).” With the

condition of only inspecting a bridge of this type once previous, the conductor had no

jurisdiction to make a choice to proceed over the bridge, not to mention there was no real

training conducted to assist him in this situation. The choice to progress regardless was a very

uneducated decision, and because of this, he falsely determined the bridge had locked. All of this

should not be put on the conductor for lack of training, but the company themselves for

disregarding what is needed for safe operation by not providing the proper training required.

From the report, the Conrail vice president/chief engineer acknowledged: “There were no written

instructions and that the training program did not cover the correct method of inspection for the

moveable bridge or its locking components when the signal aspect would not change to green

(NTSB2 2014).” Along with this, there was a conductor who had been trained in previous years

that had seen how the locks of the bridge are supposed to look when fully engaged. This

happened 4 years before this accident occurred. “During one of the conductor’s on-the-job

training trips (and only due to happenstance) the signal aspect at the Paulsboro moveable bridge

was red and would not clear. He recalled that the more experienced conductor had accompanied

him onto the bridge to inspect it before moving the train over the bridge. This event occurred 4

years before the accident and it would have been difficult to remember the details of the

inspection. Further, it is unknown whether that conductor knew how the slide locks should have

been positioned to properly lock the bridge for train movement (NTSB2 2014).” When training

employees on how the operations are supposed to work, one would think that showing them

exactly how it is intended to be done and see exactly how it is meant to look should be of the

utmost importance. This is accident is a clear result in terms of not educating the employees

enough to know what is right and wrong in the sense of knowing if the bridge is available for

operation or not, as well as to differentiate from operational or not.

An additional human factor on Conrail’s part could be either the arrogance of allowing

the bridge to remain open knowing the problems or just being uneducated to not know the risks

of allowing the bridge to remain open with the problems that it had. Technicians were unable to

determine the cause of the bridge operational failure and forced Conrail to consult an engineering

consultant to determine the problem. The consultant was unable to determine the cause and

recommended: “stop operating the bridge in advance of the December 1, 2012, seasonal

realignment for uninterrupted train traffic. He recommended the early closure to expedite the

inspection and evaluation of the electrical system to identify and fix the problems (NTSB2

2014).” Consequently, although the supervisor considered the consultant’s recommendation, he

believed that continuing operations was not critical to the safety of train operations. This choice

contributes immensely towards the end result of the train derailment. By not taking the

recommendation of a professional, one that Conrail hired to try and fix their problems, the

supervisor argued that their judgment was better that a professionals and resulted for this train to

cross the bridge with a known problem. Building off of this, Conrail puts their trust in employees

that are hired while having no previous training. “A determination of whether the bridge was safe

for train movement―which was possible even when a red signal aspect was being

displayed―depended on untrained and unqualified train crews examining the bridge (NTSB2

2014).” When someone puts their trust into a decision, especially one as technical as this, having

supporting facts or evidence behind that decision is important. This falls on Conrail’s supervisor

in the sense that they know too little on this subject and gives the power to those who are

supposed to know what to look for and diagnose the problems they are hired to identify, when in

reality, know very little.

SOLUTION

First and foremost, probably the most important solution would be to ensure that the

employees that are hired for specific job positions are not only qualified, but are trained to make

decisions in regards to their field of work without a second thought. A more specific position for

hire would be a railroad bridge inspector. According to the e-CFR, 49 CFR 237.53: “A railroad

bridge inspector shall be a person who is determined by the track owner to be technically

competent to view, measure, report and record the condition of a railroad bridge and its

individual components which that person is designated to inspect. An inspector shall be

designated to authorize or restrict the operation of railroad traffic over a bridge according to its

immediate condition or state of repair (U.S. Government Publishing Office, 49 CFR 237.53

2015).” This position will allow Conrail to maintain the rails condition and longevity, but more

importantly, safe while it is in operation. In correlation with hiring an inspector, there should be

a management program that gives guidelines on how to maintain the bridges working condition.

From e-CFR, 49 CFR 237.31: “Each track owner shall adopt a bridge safety management

program to prevent the deterioration of railroad bridges by preserving their capability to safely

carry the traffic to be operated over them, and reduce the risk of human casualties, environmental

damage, and disruption to the Nation's railroad transportation system that would result from a

catastrophic bridge failure (U.S. Government Publishing Office, 49 CFR 237.31 2015).” Not

only is this a recommendation, it is also a requirement that in Conrail’s best interests, should

adopt. Having both the inspector with their knowledge as well a plan to ensure the wellbeing of

the bridge itself, maintaining the quality in terms of safe travel will exponentially increase. With

the plan being absent and not having a trained and qualified professional to maintain the bridges

safety, this problem was bound to happen. In regards to training, Conrail should conduct a

training needs analysis. From the Rail Safety & Standards Board: “Here the aim is to ensure

either that any skills or knowledge gaps in staff performance are addressed, or that staff are

developed for future roles in the organization as part of their career development. In either case,

the training needs analysis should proceed in conjunction with the organization’s staff appraisal

process (Rail Safety and Standards Board 2008).” The reason for this suggestion is that the areas

that are either unknown are not fully understood by employees can be identified and retaught to

them, whereas past knowledge can be either retaught as a lighter touchup or passed over when

training is conducted. This process will ensure that Conrail’s employees know how to identify

the difference between the bridge itself being locked or not as well as ways to handle the

situation if they are unable to differentiate between the two.

Conclusion

In conclusion, based on what the NTSB researched and what they had determined as the

immediate reasons of the derailment, the causes were easily preventable and should not of

happened in the first place. It all starts with higher management in the sense of how they are to

educate their employees as well as to determine which employees are fit for certain jobs. Making

sure the employees being hired fit the job description as well as meet or exceed everything they

are required to do for their job is should never be overlooked, especially when safety is the main

concern. With the suggestions put forth, including the required regulations, the chance of this

exact type of accident to occur again should be significantly reduced or completely eliminated.

REFERENCES

1. National Transportation Safety Board (NTSB1).2014 July 29. Accident Reports: Conrail

Freight Train Derailment with Vinyl Chloride Release.

<http://www.ntsb.gov/investigations/AccidentReports/Pages/RAR1401.aspx>. Accessed

2015 February 26.

2. National Transportation Safety Board (NTSB2). 2014 July 29. Railroad Accident Report:

Conrail Freight Train Derailment with Vinyl Chloride Release.

<http://www.ntsb.gov/investigations/AccidentReports/Reports/RAR1401.pdf>. Accessed

2015 February 26.

3. U.S. Government Publishing Office. 2015 March 4. Electronic Code of Federal

Regulations. Title 49 CFR 237.31. < http://www.ecfr.gov/cgi-bin/text-idx?

SID=6a6092ff88cf68882ce0b15790147a0f&node=se49.4.237_131&rgn=div8>.

Accessed 2015 March 1.

4. Rail Safety and Standards Board. 2008 June. Understanding Human Factors-a guide for

the railway industry.

http://www.rssb.co.uk/Library/improving-industry-performance/2008-guide-

understanding-human-factors-a-guide-for-the-railway-industry.pdf. Accessed 2015

March 2.

5. U.S. Government Publishing Office. 2015 March 4. Electronic Code of Federal

Regulations. Title 49 CFR 237.53. < http://www.ecfr.gov/cgi-bin/text-idx?

SID=89e592bcfbef8fbc254b1308fa59cdaa&node=se49.4.237_153&rgn=div8>. Accessed

2015 March 1.