Episode 57: Hazardous Materials Branch

In this episode of Behind-the-Scene @NTSB we talk with NTSB Office of Railroad, Pipeline and Hazardous Materials Investigations’ HazMat Branch about their work to improve transportation safety.

To read some of the investigative reports discussed in this episode, visit our webpage.

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Rail Tank Car Safety Ten Years after Lac‑Mégantic

By Paul Stancil, NTSB Senior Hazardous Materials Accident Investigator

I wonder what Don Ross, the Transportation Safety Board of Canada (TSB) investigator-in-charge, might have said to commemorate the 10th anniversary of the train derailment that occurred in Lac‑Mégantic, Quebec: a tragedy that claimed 47 lives, forced about 2,000 people to evacuate, and destroyed 40 buildings and 53 vehicles. It was my somber privilege to lead a team of NTSB investigators to that devastating accident scene to assist the TSB.      

Sadly, Don passed in 2019. But I am certain that he would have expressed gratitude for the dedication and personal sacrifices of his team members who, despite the massive scale of the task before them, organized quickly to get the job done. And I know he’d talk about how the appreciation and trust offered by families of the victims kept them going.

I wish I were visiting the accident scene with my friend Don to reflect on the enormous impact of this event. I’d tell him that he and his team didn’t just set the standard for how investigations of this magnitude should be done; the lessons they uncovered are still saving lives across Canada and the United States.

Lac-Mégantic town center, July 7, 2013. Courtesy: Transportation Safety Board of Canada.

What Happened

The events that led to this derailment began on July 5, 2013, at 10:50 p.m. local time, when Montreal, Maine & Atlantic Railway (MMA) freight train MMA-002 enroute from Montréal, Quebec, to Saint John, New Brunswick, Canada, via Brownville Junction, Maine, came to rest at a crew change point near Nantes, Quebec. The track had a descending grade toward the town of Lac-Mégantic. The train was carrying volatile Bakken petroleum crude oil, a flammable liquid, that originated from New Town, North Dakota, destined for an oil refinery in Saint John, New Brunswick. The train was composed of five head-end locomotives, a special‑purpose caboose equipped to remotely control the locomotives, one loaded boxcar used as a buffer car, and 72 DOT-111 general service tank cars.  

The train was operated by a single locomotive engineer, who left the lead locomotive idling after setting hand brakes on the locomotive consist and buffer car (seven cars in total). The locomotive engineer reported to the MMA rail traffic controller located in Bangor, Maine, that he had experienced mechanical difficulty with the lead locomotive throughout the trip and excessive smoke was coming from the engine. The engineer and rail traffic controller agreed the condition would likely settle on its own and the performance issues could be dealt with the next morning. The locomotive engineer then departed the area, leaving the idling lead locomotive and train unattended on the mainline track.

About 11:40 p.m., a local resident reported a fire on the idling locomotive. The fire department responded, and the MMA dispatched an employee to assist the fire department personnel. About midnight, the responders activated the emergency fuel cut-off switch to shut down the locomotive and extinguished the fire. The fire department and MMA personnel then departed the location, leaving the train unattended.

With no locomotive running, the air in the train’s brake system slowly began to deplete, resulting in a reduction in the retarding force holding the train in place. Shortly before 1:00 a.m. on July 6, 2013, the unattended train started to move, and it gathered speed, rolling uncontrolled for 7.2 miles down the descending grade into Lac‑Mégantic. The train reached a speed of about 65 mph as it entered the center of Lac‑Mégantic, where 63 loaded crude oil tank cars derailed on a curve and caught fire.  

To this day, the Lac-Mégantic derailment remains the worst dangerous goods railroading disaster in Canadian history. At least 60 of the 63 derailed DOT-111 tank cars released about 1.6 million gallons of crude oil. Some of the spilled oil ignited immediately and engulfed the derailed tank cars, resulting in cascading fires and explosions. More than 26,000 gallons of the released crude oil entered Mégantic Lake and the Chaudière River. The fire wasn’t extinguished until around noon on July 7, 2013.

Rail Car Safety at the Forefront

I was preparing for an NTSB investigative hearing on another derailment with hazardous material release when I first learned about Lac‑Mégantic. Before we knew the details, I found myself hoping that the Lac-Mégantic train was not composed of many DOT-111 tank cars.

Based on our own experience with train derailments going back to the 1990s, my NTSB colleagues and I knew that this type of tank car performed poorly in an accident. Between 2007 and 2012, alone, there were several derailments with major flammable liquids releases and fires involving DOT-111 tank cars.

• New Brighton, Pennsylvania: 23 derailed DOT-111 cars lost over 485,000 gallons of denatured ethanol on October 20, 2006.
• Cherry Valley, Illinois: 19 DOT-111 tank cars carrying ethanol derailed on June 19, 2009, killing one person and injuring seven others who were stopped in automobiles at a grade crossing. We concluded that enhanced tank head and shell puncture-resistance systems such as head shields, tank jackets, and increased shell thicknesses could have significantly reduced the severity of the accident.
• Arcadia, Ohio: 33 derailed DOT-111 tank cars released about 786,000 gallons of ethanol on February 6, 2011.
• Tiskilwa, Illinois: 10 DOT-111 tank cars derailed, resulting in fire, energetic rupture of several tank cars, and the release of 162,000 gallons of ethanol on October 7, 2011.
• Columbus, Ohio: Three derailed DOT-111 tank cars released about 53,000 gallons of ethanol on July 11, 2012; one of the derailed tank cars experienced energetic rupture.
• Plevna, Montana: Five of 18 derailed DOT-111 tank cars carrying ethanol caught fire on August 5, 2012, resulting in explosions.

Sadly, the degree of urgency for immediate regulatory action following these accidents was not commensurate with the potential for harm.

Recognizing the growing problem, however, the Association of American Railroads (AAR) Tank Car Committee had begun an effort in July 2009 to improve the accident survivability of DOT-111 tank cars transporting petroleum crude oil, ethanol, and ethanol/gasoline mixtures. Thus, in the absence of any new federal regulatory requirements, builders began producing new “CPC-1232” tank cars that used thicker steel for greater tank head and shell strength.

Several days after the Lac-Mégantic derailment, our worst fears at the NTSB were confirmed: all 63 of the derailed tank cars were DOT‑111s.

An Incredible Partnership

Given our history of safety recommendations citing safety deficiencies in DOT-111 tank cars and our newly acquired ability to laser scan tank cars, the TSB soon reached out to the NTSB to assist in its investigation. That is how I came to lead a team of five NTSB investigators to Lac-Mégantic, where we helped examine the derailed tank cars. A sixth NTSB investigator deployed to the oil shipment’s point of origin in North Dakota.

As a result of our collaborative examination of the derailed tank cars, we found that the train was solely composed of “legacy” DOT‑111s that incorporated basic 1950s technology for general service. The TSB determined that 94% of the derailed cars were breached in some way. Further, more than half of the shell-breaching damages were equal in size to the car’s diameter, which resulted in massive instant loss of product.

NTSB investigators adjust laser scanning equipment next to a damaged tank car in Lac-Mégantic, July 25, 2013.

During this investigation, we also discovered that railroads were not required to conduct analyses to ensure safe transport routes for flammable liquids, a requirement that did apply to other high-hazard materials.

Because the MMA had not ensured response resources would be available to remove a potential crude oil discharge of this size, Canadian authorities were left to complete the cleanup. We found a loophole in US federal regulations that established a comprehensive oil spill response planning threshold for a single tank size that was greater than any currently in use. In other words, had this derailment occurred in the United States, the rail carrier’s lack of oil-spill planning would have required the federal government to initiate removal actions using the Oil Spill Liability Trust Fund to pay for the costs.

Finally, the shipper in North Dakota had incorrectly classified the crude oil as a Packing Group III material, meaning it presented the lowest degree of danger in transportation. However, TSB’s testing found that the crude oil should have been assigned to the more hazardous Packing Group II. Not only could misclassification affect the type of tank car used to ship the hazardous material; it also could have affected other safety provisions, such as outage requirements, operational controls, and safety and security planning for the train. The misclassification also could have hampered emergency responders’ ability to correctly understand the hazards associated with a shipment.

Impact on Tank Car Design

In January 2014, the TSB and the NTSB, in unprecedented action, jointly issued safety recommendations to remedy deficiencies that impacted the safety of rail operations both in Canada and the United States. Our recommendations were coordinated in recognition of the cross-border nature of hazardous materials rail shipments. This approach proved to be a call to action for improving the safety of operating freight trains that later came to be known as high-hazard flammable trains. Our combined voice was also beneficial for eliminating confusion about what had to be done.

Within 2 months of the Lac-Mégantic accident, the Pipeline and Hazardous Materials Safety Administration (PHMSA) addressed four of our safety recommendations dealing with improving tank car standards and improving the availability of hazardous materials information to emergency responders.[1] Other freight rail safety improvements soon followed.

• January 2014: Transport Canada proposes a new standard for DOT-111 tank cars that included thicker steel, top fittings protection, and head shields.
• April 2014: Transport Canada orders the least crash-resistant DOT-111 tank cars removed from service; the NTSB holds a Rail Safety Forum on the Transportation of Crude Oil and Ethanol in response to the 16 significant derailments in the United States and Canada which, combined, were responsible for 48 deaths and 281 derailed DOT-111 tank cars that released 2.8 million gallons of crude oil and 2 million gallons of ethanol.
• August 2014: Citing Lac-Mégantic as justification, PHMSA considers a new specification DOT-117 tank car, which, among other things, would be required to have a thicker shell than the CPC-1232 tank car, full head shields, and tank jackets with thermal protection system.[2]
• Early 2015: A spate of fiery derailments fuels public outcry over so-called “bomb trains.”
• April 2015: the NTSB recommends that all new and existing tank cars used to transport flammable liquids be equipped with thermal protection systems and appropriately sized pressure relief devices. We also recommended an aggressive milestone schedule for replacement or retrofitting legacy DOT-111 and CPC-1232 tank cars and a publicly available reporting system for its progress.
• May 2015: PHMSA imposes restrictions on high-hazard flammable trains, ensures proper classification of unrefined petroleum products, and codifies new tank car design standards for DOT-117 tank cars. Transport Canada harmonizes Canadian regulations to reflect the new tank car design standards.
• December 2015: President Obama signs the Fixing America’s Surface Transportation Act of 2015 (FAST Act) into law, which instructs the Secretary of Transportation to make specific regulatory amendments to tank car design standards and establishes a phase-out schedule.
• August 2016: PHMSA codifies the FAST Act mandates by requiring newly manufactured DOT-117 and retrofitted tank cars meeting DOT specification 117R to be equipped with a thermal protection blanket and top fittings protection.

The Work Ahead

According to the latest AAR figures, more than 92,900 tank cars in the North American fleet meet DOT-117 specifications, while about 33,600 total DOT-111 and CPC-1232 tank cars remain to be retrofitted or phased out of flammable liquids service.[3]

As we have watched the flammable liquids fleet transition away from DOT-111 tank cars in recent years, there have been fewer derailments of high-hazard flammable trains. Although declining accident numbers could certainly be due to a significant decrease in petroleum crude oil shipments since 2014, a steady volume of ethanol continues to fill between 300,000 and 400,000 carloads per year.

However, thanks in large part to increased puncture resistance, service equipment protection, and thermal protection systems, there has not been a single death or serious injury, nor a single instance of energetic fireball release or boiling liquid expanding vapor explosion (BLEVE) involving a derailed specification DOT-117 tank car transporting flammable liquids. The Lac-Mégantic investigation has remained the cornerstone for these safety improvements.

Nevertheless, there continue to be incidents and near-misses; more work is needed to improve rail tank car safety. For example, recent derailments have revealed vulnerabilities in the thermal performance of gasket materials, hinged and bolted manways, and service equipment. This includes the following four derailments with hazmat release that the NTSB is currently investigating:

• The January 8, 2022, derailment of a high-hazard flammable train in Oklaunion, Texas, in which 28 derailed DOT-117J tank cars released almost 602,000 gallons of ethanol, largely due thermal damage of manway gaskets and other service equipment.
• The February 3, 2023, train derailment with hazardous material release and fires that occurred in East Palestine, Ohio, in which a mixed freight train derailed 11 tank cars carrying hazardous materials, including three DOT-111 tank cars that were punctured and released flammable and combustible materials that ignited. The resulting thermal damage to other tank cars carrying vinyl chloride prompted a controversial vent-and-burn action that released toxic combustion products into the surrounding community.
• The March 30, 2023, derailment of a mixed freight train in Raymond, Minnesota, including 10 DOT-117J tank cars carrying ethanol, some of which was released from two punctured tank cars and ignited and caused thermal damage to manway gaskets in other tank cars.  
• The June 24, 2023, freight train derailment in Reed Point, Montana, in which nine DOT-111 tank cars carrying hazardous materials derailed from a bridge and came to rest in the Yellowstone River, where they released molten sulfur and asphalt petroleum liquid into the river.

Thinking back on those lost in the Lac-Mégantic tragedy, I can’t help but remember something Don once told me: “I think it is fair to say that no one can be fully prepared for this.” That may be true, yet Don and the TSB team more than rose to meet the occasion. And we are all safer for it.

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[1] Safety Recommendations R-12-5, R-12-6, R-12-7, and R-07-4 (reiterated).  

[2] 79 Federal Register 45016 (August 1, 2014)   

[3] North American Flammable Liquid Tank Car Fleet: Status Report, 4th Quarter 2022, (Association of American Railroads, April 2023).

Rightsizing our Agency with the Right Resources at the Right Time

By Dana Schulze, NTSB Managing Director

The National Transportation Safety Board (NTSB) is an independent federal agency charged by Congress with investigating every civil aviation accident in the United States and significant events in railroad, transit, highway, marine, pipeline, and commercial space. We determine the probable causes of the accidents and events we investigate and issue safety recommendations aimed at preventing future occurrences. 

The agency’s investigative and technical staff are recognized for their forensic safety expertise, and with support from the agency’s professional staff, the NTSB is the premier safety investigation organization in the world. In total, the NTSB has conducted more than 153,000 aviation-related investigations and thousands of highway, transit, marine, rail, pipeline, and commercial space investigations, resulting in more than 15,300 safety recommendations. As a result, the NTSB has had a significant and far-reaching impact improving transportation safety for all, with 80% of our recommendations being addressed.

We’ve been getting the job done, even though our budget and workforce has remained relatively flat for the past 20 years. That’s until the 15th Chair of the NTSB, Jennifer Homendy, was sworn in on Aug. 15, 2021.

From her first day, Chair Homendy immediately began implementing her vision of putting mission first, building our agency’s staffing and infrastructure to equip us to better meet the transportation safety challenges we face, including today’s accidents and significant events and those coming in the very near future from emerging technologies like autonomous vehicles and commercial space.

Growing our Workforce

Her first step: fund the agency to grow our workforce. Chair Homendy understood that the agency could not effectively operate with the same number of people that we had in 1997, given the growing complexities of the transportation systems we investigate. Working with leadership across the agency, the Chair secured needed funding increases in fiscal years (FYs) 2022 and 2023, prioritizing recruitment of a diverse and talented workforce, starting with hiring the agency’s first chief human capital officer and supporting a hiring surge.

Under Homendy’s leadership, our workforce has rebounded from an all-time low of 397 employees in August 2019 to its current 419 dedicated professionals. The NTSB workforce is expected to grow to 435 employees by the end of September.

Chair Homendy and Office of Aviation Air Traffic Control Team

Chair Homendy routinely swears in new staff as they are welcomed into the agency by our senior leaders. Just this week, the Chair gave the oath of office to a returning NTSB employee joining our Office of Research and Engineering and new members of the Air Traffic Control Team within the Office of Aviation Safety. That division is now fully staffed for the first time in 7 years.

We also have Chair Homendy to thank for successfully asking the Office of Personnel Management to grant us direct-hire authority, which has sped up the hiring process and enabled us to identify and hire the right talent, for the right job, faster.

Getting Up to Speed Quickly

With so many new hires, agency leaders are focused on ensuring all staff have the skills to succeed. Staff now have access to a Career Development Roadmap with a curated list of educational resources in emerging technology, leadership, project management, data analytics, and many other areas critical to our mission success. We’ve developed and launched a multimodal drone program, including new drones and training for drone operators.

We even launched a new mentoring program in 2023 to connect our seasoned veterans with our newest members to help transfer their knowledge, skills, and expertise. We kicked the program off with a speed mentoring event featuring female leaders across the agency during Women’s History Month.

Women’s History Month Mentoring Event

We’re also investing in our infrastructure, prioritizing funding to acquire long-overdue enhanced IT tools and digital capabilities to improve the customer experience of both staff and those seeking information from the NTSB. This will be supported by the $16.2 million Technology Modernization Fund loan recently awarded to our agency, thanks to an agencywide team led by the Office of Chief Information Officer (CIO) in coordination with the Office of Managing Director, the Office of the Chief Financial Officer, and the Office of Human Capital Management and Training.

If you’ve met Jennifer Homendy, you know she’s a people person. She’s always out there building relationships in big and small ways, internally and with external stakeholders. Our recent ice cream social, co-hosted by the agency’s staff-led Diversity and Inclusion Council (“the DIAC”) and my office, is one example of the Chair’s efforts. The social was a great opportunity to break down our organizational silos, help our new staff feel welcome, and assure everyone that we’re all focused on the same core mission, no matter what your role, as part of Team NTSB.

Driving Change with Data

Ensuring our agency leaders have the data they need to make critical decisions, improve our operations, and swiftly answer data calls from Congress and the public has been a top priority for Chair Homendy. 

As a result, the NTSB now has a formal Data Program and Data Strategy Plan. We’ve also hired a chief data officer, who will join our agency in early FY 2024. Already, with the help of our chief data scientist and CIO, our data infrastructure has grown to allow staff use dashboards and data visualization tools to help analyze the agency’s work, identify trouble spots and bottlenecks, and make changes to improve efficiency.

The proof of success from our data-driven change and larger workforce is in the numbers. Over the past 2 years, thanks to staff’s incredible work, we’ve reduced our backlog of 442 incomplete investigations over 2 years old to almost zero, and the average time to complete an investigation has decreased across every mode of transportation we investigate. Now, that’s measurable progress!

Rightsizing our Budget 

Growth and operational improvements come at a cost—a fact not lost on Chair Homendy. For the past 2 years, the Chair has been on Capitol Hill knocking on doors and speaking to everyone who will listen about why our agency’s budget needs to be rightsized. 

She has also spent the past 2 years proving to Congress that this agency is responsive and nimble, and that we’re improving our operational efficiency. All her efforts to grow our staff, reduce our investigation backlog, and better serve and represent our customers are paying off. 

For FY 2024, the House Appropriations Committee approved a $145-million budget for our agency. If granted, it would be the first significant NTSB funding increase since the mid-1990s. The new funding has long been needed to continue to grow the agency’s size and capabilities so we can more effectively accomplish our critical safety mission.

We look forward to entering the new fiscal year energized, better staffed, and prepared to meet new challenges, with a new group of NTSB employees ready to join in our critical mission to make transportation safer for all. 

Prioritizing Safety This Holiday Travel Season

By Stephanie Shaw, Acting Chief, NTSB Safety Advocacy Division

This week, families and friends will gather to celebrate the Thanksgiving holiday. According to estimates from AAA, nearly 55 million people will travel away from home this year, with about 49 million of them taking to the roads.

As we mark the beginning of the holiday travel season, we want to ensure that everyone arrives safely at their destinations. Unfortunately, travel on our roads can be the riskiest mode of travel during the holiday season.

NTSB investigations continue to highlight actions needed by regulators, legislators, and industry to ensure the safest transportation system for the traveling public. Our Most Wanted List (MWL) identifies specific transportation safety improvements needed across all modes. It includes five road safety improvements that address pervasive problems like speeding, alcohol and other drug impairment, and distraction. The MWL also calls for collision-avoidance and connected vehicle technologies and implementation of a Safe System Approach to better protect all road users.

At the NTSB, we believe that safety is a shared responsibility, so for the traveling public, we’ve highlighted some ways you can keep yourself and others safe, regardless of the travel mode you choose.

By Car

Impairment by alcohol and other drugs, unsafe speeds, fatigue, and distraction continue to play major roles in crashes. Here’s what you can do:

• Designate a sober driver, or call a taxi, or ridesharing service if your holiday celebrations involve alcohol or other impairing drugs.
• Follow safe speeds. In bad weather, safe speeds are often below the designated speed limit. Speeding increases the chance of being involved in a crash and intensifies the severity of crash injuries.
• Make sure you’re well rested! A fatigued driver is just as dangerous as one impaired by alcohol or other drugs.
• Avoid distractions. Don’t take or make calls or text while driving, even using a hands-free device. Set your navigation system before you start driving. If you’re traveling with others, ask them to navigate.
• Make sure to use the correct safety restraint for child passengers, and be sure it’s installed correctly.
• Ensure you and all your passengers are buckled up! In a crash, seat belts (and proper child restraints) are your best protection against death and serious injuries.

By Bus

The NTSB has made recommendations to improve motorcoach operations and vehicle crashworthiness, but travelers should know what to do in an emergency.

• Pay attention to safety briefings and know where the nearest emergency exit is. If it’s a window or roof hatch, make sure you know how to use it.
• Ask your driver to give you a safety briefing if you’re unsure of where the exits are or how to use them.
• Use your seat belt when they’re available!

By Plane or Boat

These tips can help you and your loved ones in an emergency on planes or vessels.

• Pay close attention to the safety briefing! Airline and marine accidents have become very rare, but you and your family can be safer by being prepared.
• Know where to find the nearest emergency exit and flotation device whether you’re on an airplane or a boat.
• Confirm that you and your traveling companions—even children under age 2—have your own seats and are buckled up when flying.
• Don’t forget your child’s car seat. The label will usually tell you if your child car seat is certified for airplane use; the owner’s manual always has this information.
• Call the airline and ask what the rules are for using a child’s car seat on your flight, if you don’t already know.
• Follow crewmember instructions and remain calm in an emergency.

By Train

The NTSB has made recommendations to improve passenger rail operations and vehicle crashworthiness, but travelers should also follow these safety tips.

• Stow carry-ons in the locations provided (overhead and racks). Don’t block aisles.
• Review your trains safety information which may be provided as a safety card in your seat pocket or displayed in your railcar.
• Follow crewmember instructions and remain calm in an emergency.

No matter how you travel, make a commitment to put safety first.

We wish everyone a safe and happy Thanksgiving.

Improving Safety in the Second-Largest Continent

By Nicholas Worrell, Chief, NTSB Safety Advocacy Division

In August, 2019, I wrote that Safe Skies for Africa was ending, but that the safety journey would go on in Africa, the world’s second-largest and second-most-populous continent. Earlier this month, it was my pleasure to represent the NTSB in a presentation about best practices in safety advocacy at the Civil Aviation Operational Safety Workshop in Cape Verde.

The occasion was Aviation Safety Week, which gathered together transportation safety leaders from seven African nations, the EU, and the United States to share safety knowledge. Attendees were interested to learn from my presentation that in the United States, the accident investigator—the NTSB—has no power whatsoever to require change.

Enter Advocacy.

It’s been said that information + persuasion = advocacy. The idea is never to misrepresent; rather, it is to present information that makes the case most compellingly. If the case is compelling enough, your advocacy might inspire people to act. Then, they might influence others to act as well, creating a critical force multiplier. I spoke to my audience about advocacy methodology, messaging, and tools, and the absolute need for collaboration, working with and through others. I reminded my audience, though, that advocacy differs with the context and the organization. At the NTSB, for example, it’s the one way we can bring about change and encourage implementation of our recommendations. However, I urged safety leaders in Africa to be mindful that all advocacy is local. What might work in the United States might not necessarily work for all of Africa.

Ultimately, wherever it is done, advocacy done right moves the needle toward saving lives. As transportation safety leaders, I told my audience, we must communicate our work to gain the desired impact and outcomes. We must be proactive and go to our audience, not sit back waiting for them to come to us.

It was an honor addressing these passionate transportation safety leaders from the African region. We should always remember that our transportation safety work crosses air, land, and sea. When we share our lessons learned and best practices, and when others share theirs with us, we may save lives not just nationally, but globally, as well.