AIKEN - The National Transportation Safety Board ruled Tuesday that the "probable cause" behind the Graniteville train crash and chlorine release was an improperly aligned track switch.
The three-member, presidentially appointed panel announced its decision at a public meeting on the crash in Washington, officially concluding a federal investigation that started soon after the Jan. 6 disaster.
The board's decision confirmed what investigators said they suspected from the start: After the three-man crew of Norfolk Southern Train P22 parked their locomotive on a side track outside Avondale Mills Inc., they left the track and didn't realign the switch.
It was a mistake that later sent Norfolk Southern Train 192 barrelling from the main track and into the parked locomotive, puncturing a chlorine tanker in tow and releasing an estimated 60 tons of chlorine.
Nine people were killed by the toxic spill and hundreds more were injured.
"This was a tragic chain of events that did not have to happen and unfortunately resulted in the loss of life," Mark Rosenker, the acting NTSB chairman, said in a prepared statement. "The board can not stress enough the importance of following proper procedures and protocols, at all times, when operating these massive machines."
The board, which reviewed findings from an in-house investigation before releasing its conclusions, attributed the misaligned switch to several factors: the function of re-aligning the switch was isolated from other tasks; the Train P22 crew was rushing to complete its work before its 12-hour window expired; the switch could not be seen as the crew worked, leaving them without a visible reminder of its position.
The board also found that if the conductor of Train P22, Jimmy Thornton, had "held a comprehensive job briefing ... as required by Norfolk Southern operating rules, the crew may have attended to the main line switch, and the accident may not have occurred."
Mr. Thornton, along with Train P22's engineer Benjamin Aiken and brakeman Mike Ford, all have been fired by Norfolk Southern.
To prevent similar mistakes in the future, the NTSB also recommended that Federal Railroad Administration require railroads to:
- install devices that "compellingly capture" the attention of train crews and alert them to the position of a track switch
- operate trains in nonsignaled territory, or "dark territory," similar to Graniteville at speeds that allow them to stop in advance of improperly aligned switches
- position hazardous materials at the rear of a train to lessen the possibility of disaster, along with decreasing speeds when traveling through populated areas such as Graniteville
- provide breathing devices to crews carrying hazardous materials
The railroad administration already has taken measures since the Graniteville accident to shore up switch safety, including an emergency order that required all of the country's 600-plus railroads to review track switch guidelines with appropriate personnel and, in some cases, strengthen operating rules.
"As we all know, the major issue with the Graniteville case has been switch safety in dark territory, and we have taken aggressive action in regards to that issue," administration spokesman Steve Kulm said.
He said his agency would respond in writing to each of the NTSB's recommendations.
Norfolk Southern is studying the NTSB's report and declined to comment on its safety recommendations until after further review.
Others needed less time.
"Rail companies must act now to implement changes recommended by the NTSB to protect the public," said John Murphy, the director of the International Brotherhood of Teamsters Rail Conference, in a prepared statement. "Our country cannot afford to wait for the (FRA) to force these corporations to do what is right."
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